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One ER doc's take on what's driving healthcare costs inexorably higher

I received an e-mail this morning from Dr. Robert W. Robertson Jr., former director of emergency services at Western Baptist Hospital in Paducah, Ky., who now practices preventative medicine in that community. He was responding to one of my previous healthcare posts, and he gives the clearest explanation I've heard yet about why people with health insurance have a financial interest in extending coverage to the uninsured. He doesn't get into the issue of illegal immigrants, so I'll take that up in a later post. Besides, everyone else here is writing about Joe Wilson, so I'm feeling some pressure to do my part.

Dr. Robertson's piece follows below.

-- Jon Healey

With the healthcare debate becoming more unruly and with people who are earnestly trying to address the situation  being shouted down without having a chance to speak, I’d like to have those who are acting in such a strident manner make an effort to understand the reason that health care expenditures are on an unrelenting, accelerating, upward spiral, and why changes must be implemented.

It is a simple fact that it is the uninsured who are driving up the cost of healthcare for everyone.

Here are the facts.

In 2005, there were 44.8 million who had no medical insurance. In 2006, that number had grown to 47 million. Presently, it is estimated that there are 50 million who have no coverage, and that number will rise to over 52 million at the end of 2010.

As a former director of a hospital emergency department seeing over 50,000 patients annually, I am very aware of how the medical system works.

Anytime an uninsured person enters a hospital emergency department and registers in, the minute they cross the threshold, the hospital is mandated to (1) evaluate, and (2) make a disposition of the individual.

That disposition may be to: (1) reassure that no treatment is required; (2) provide appropriate treatment; (3) admit to the facility; or (4) make a referral.

If the hospital is unwilling to evaluate and make a disposition, it will lose reimbursement from Medicare and Medicaid programs, which is tantamount to financial suicide.

No matter what the ultimate disposition, the hospital incurs costs that are not reimbursed.

Hospitals have huge fixed costs which must be covered in order to operate the facility. Also, hospitals must have available resources to constantly be able to invest in new technologies in order to best provide service for those seeking care.

Thus is set in motion the unrelenting, upward spiral of ever-increasing medical costs.

  1. The uninsured numbers are constantly increasing.
  2. The unreimbursed expenses incurred by hospitals in treating those ever-increasing numbers of the uninsured are constantly increasing.
  3. Hospitals must increase their charges in order to cover the ever-increasing costs of treating the uninsured.
  4. Medical insurance companies must increase the premiums of those they insure in order to pay for the increased hospital charges when their insureds seek treatment.
  5. Each time insurance premiums increase, another portion of the population opts out of carrying insurance. Individuals or companies reach a point, finally, when they can no longer afford insurance, and individual policyholders or employees of companies which drop their benefits enter into the pool of the uninsured.
  6. More uninsured people = increased, unreimbursed hospital costs = increased hospital charges = increased insurance premiums = more uninsured people.... The upward spiral is incessant.

The pressure created by the ever-increasing number of the uninsured is the driving force behind the ever-increasing cost of medical care in the United States. That force is unrelenting. It can only accelerate. It has created a system which is unsustainable.

Other than refusing to offer treatment to those who are uninsured, there is no mathematical model which can be proposed that can slow or halt the inevitable, continuing rise in healthcare costs without removing the uninsured from the equation and including them in the system.

If we fail to address the underlying reason for the situation we find ourselves in, the ever-increasing numbers of the uninsured, the medical care delivery system, severely strained at present, will eventually break.

No rational person on either side of the aisle could want that to happen.

I would encourage people to enter into a civilized debate about healthcare in our country, all the while reminding them that each citizen has a responsibility to consider the consequences if we don’t take action before any action we may take is too little, and too late.

We simply must consider and include all of the uninsured into whatever plan is ultimately adopted. There is no other option available.

Those who simply shout down our elected officials who are attempting to rationally address our healthcare delivery crisis offer no solutions.  Their actions are a disservice to each of us.

-- Robert W. Robertson Jr., M.D.


Comments () | Archives (30)

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Not a workable idea, as long as the numbers of "uninsured" keep spiralling upwards due to our "government's" inability to enforce our immigration laws. In other words, if you continue to import poverty, your proverty levels go up. Shocking idea, isn't it?

Jon Healey

@MaryJ -- The percentage of the uninsured who are immigrants is high compared to native borns, but it's dropping. In addition, immigrants -- legal and otherwise -- consume fewer healthcare services per capita than native-born Americans. So although immigrants contribute to the problems caused by the uninsured, I don't think you can say they're the driving force.

Tony R

I wonder if the fact that everybody who works in a hospital feels like they should make six figures has anything to do with the increasing costs?


Thank you, Dr. Robertson, for a clear and virtually irrefutable explanation of a problem and its solution. This cogent piece of writing should be required reading by not only our elected officials, but also all of our eligible voters.

Linda Blum

Dr. Robertson's blanket assertion that the uninsured cause unreimbursed hospital ER costs is not true in my case. Both times I used our local ER I paid my bills in full; the third time I needed to use an ER, I sat out my heart arrhythmia at home instead because I couldn't afford treatment. One thing a nurse pointed out to me as a "self-pay" patient during my last hospital visit is that insured patients get better prices because their companies bargain with the hospital companies. So I paid my bill at higher prices than what an insured person would incur, and am still slandered in the public debate.


that is why we need immigration reform!!!


I view this as another example of how mandates on caregivers, while attempting to solve a particular problem, also end up creating unintended adverse consequences.

If people know they will be treated for free at the nearest ER regardless of whether or not they're insured, it creates a disincentive for people to bother with insurance. Thus our emergency rooms are often misused, and hospitals are driven out of business. If the mandates were lifted, allowing consumers, caregivers, and insurers to contract freely with each other, the cost of care would come down.

Sal B


"If people know they will be treated for free at the nearest ER regardless of whether or not they're insured, it creates a disincentive for people to bother with insurance. Thus our emergency rooms are often misused, and hospitals are driven out of business. If the mandates were lifted, allowing consumers, caregivers, and insurers to contract freely with each other, the cost of care would come down."

Certainly, Earl, if you get into an auto accident and are unconscious, that's a great time to enter into contract discussions.

What planet do you spend most of your time on?

Health care, for the most part, is *not* a discretionary expense. You don't go shopping around when you need it, you have to have it at once or as soon as possible. Thus, the ideas of shopping and bargaining for it are absolutely nuts.


"In addition, immigrants -- legal and otherwise -- consume fewer healthcare services per capita than native-born Americans." John Healey

Unfortunately Mr. John Healey is ill informed on this issue. He has obviously never been to an emergency room in the greater Los Angeles area. If he had, he'd know that every day, the emergency room is filled with illegal immigrants who use it as their primary care facility since they have no insurance.

So, when an 84 year old woman with insurance goes into the emergency room for a valid emergency, she has to wait for hours, puking in a bucket, before a doctor can see her, because of this illegal immigrant problem.


Linda Blum -

Did you even read the article?

Richard P

This is only one contributor to rising costs. Robertson cites technology upgrades as a major cost, and then ignores it afterward. He fails to mention that insurance companies consume a lot of dollars, but produce nothing, and that drug companies are extremely inefficient, with profits, bloated management salaries, and marketing consuming a large fraction of their gross income. Another major problem is that reimbursement schemes sometimes encourage not treating a disease inexpensively at early stages, then treating it later when it is more profitable to do so. The NY Times ran an article about this a while back; the doctors lost money on early diabetes care, but the surgeons profited on foot amputations caused by withholding that early care.


Another way to view this is that everyone IS insured, it's just that 48 million of those people pay NO premiums, and get even routine care from the most expensive of the many possible medical venues - and often not until they're far more ill than they needed to get.

The current approach makes neither fiscal nor medical sense. We can, and should, do better.


"no rational person on either side of the aisle." with all due respect, doctor, the right-hand side of the aisle is not rational. They have no plan to cover the uninsured. I would also add that though the forces you note here are absolutely a major factor in the cost of medicine, doctors cannot get off the hook. In certain parts of the country, doctors order procedures like candy for their insured patients. In other parts of the country - Rochester, MN is the best example - doctors are much more careful and only treat and test when science indicates doing so is helpful. The difference? Doctors who jack up costs with unnecessary tests and procedures (usually tests and procedures their patients are not clamoring for) get paid as FEE FOR SERVICE. In Rochester? Most docs are on SALARY, and the Mayo Clinic has very well established panels (I guess our friends on the right would call them death panels) determining what procedures and tests should be recommended by doctors. Citizens of Minnesota are among the longest lived in the country so clearly this is not causing any compromise in care.

As an ER Doc, you may be on salary. But you need to open your eyes and realize that hundreds of thousands of other doctors are getting paid by insurance companies and medicare for every test their order. And that, combined with the uninsured, is driving costs upward.


To Linda Blum. I am a nurse. The ER doc was talking about uninsured people who do NOT pay their bills...not people like you who are 'cash pay' You actually make the hospital money!!!


@RichardP: I dare you to name just one real example of a doctor with-holding diabetes care just so they can profit from an amputation. You, sir, are a bigoted buffoon. Dr Robertson's analysis is simplified in many ways, probably not to confuse the general public but the gist of his article is true. I've worked in many hospitals and the percentage of illegal aliens in the indigent population is exploding exponentially. Since it is not palatable to the general public to deny care or to provide care and then deport, the only solution is to detect and deport and prevent entry in the first place. Otherwise, bankruptcy of the medical system and eventually the US treasury is assured. Otherwise, why even have a border? Take anyone who can be carried across the magic line and give them everything this country can provide---food, housing, medical care, education, even a vote. RIP, America 1776-20??


Oh how wrong you are. I am hardly alone in this: I save the medical industry thousands of dollars. I am uninsured. I am taking care of my chronic illnesses by myself. I have learned how to do this much better than any M.D. could. I diagnosed my own hypothyroidism and take care of it. The difference in my life is astonishing. I diagnosed my own metabolic issue and began d-ribose. I have gone from a couch potato to an active bike riding, swimming, happy, energetic person. There was a time I lost energy from talking. D-ribose changed that. I have autoimmune illnesses that I take care of with low dose naltrexone (ldn). The cost is less than $1.00 per day.

This one drug alone (off patent) could save billions. Think it is snake oil? Think again. Stanford just finished a clinical trial for fibromyalgia. Penn State just finished one for Crohn's. Both had excellent results. Go watch the youtube video of the doctors using it for many cancers. Interested in saving people's lives at a fraction of the cost? Ready to walk the talk? Go google ldn and cancer or ldn and autoimmune. GO!

Lisa Porter

I don't understand this going to the ER and not paying. I've been sent to collections for ER bills my insurance didn't pay. I believe everyone should pay something; maybe on a sliding scale dependent upon income. Maybe we should go back to the old model: medical services for the uninsured would be provided only by public hospitals. The government would play a role in providing more support to these public hospitals. Also more low cost clinics should be opened so that people could stop using ER rooms for non emergency situations.


Are we talking about people without health insurance who won't even attempt to pay their bill?
That's the problem—there is no such thing as free medical care, nor should there be. Takes responsibility off of the individual and puts it squarely on the shoulders of working people who end up paying for deadbeats.
No one is denied medical care—but paying medical bills is something too many people refuse to do.
Signed, someone with a $25 co-pay and 80% coverage who has to save $$$ for a doctor's visit, and I'm not waiting on the government to give me that $$$$.


First of all, I would like to say that my brother's comments totally hit the nail on the head. There are a couple (actually multiple) of other nails that need to be hammered:
(1)MALPRACTICE REFORM: I retired from the practice of Ob-Gyn on 4/1/08 to avoid writing a check for $65,000 for one year of insurance and that is cheap compared to others in many states. The practice of defensive medicine will go on unabated as long as doctors are looking over their shoulder to see if the plantiff lawyer will later cite them for not ordering a certain test. An example of this is the CAT scan that every patient gets in the ER. Any hope of reform has no chance unless we have malpractice reform.
(2)FEE FOR SERVICE: The current system of the more you operate or hospital patients the more you get paid provides only the incentive to continue the upward spiral of healthcare costs. George W. Roberton, M.D.


I think it's a cop out to blame the uninsured for the outrageous state of medical care in this country. Physicians in the United States practice the same code of ethics as garage mechanics. Many doctors are competent and reliable - many take advantage of patients with unnecessary and overpriced treatment.

Take, for example, the overuse of MRI's. It's the multi-billion dollar gift that keeps on giving. Neither the insurance industry or the medical profession have disclosed publicly how many MRI's are a waste of time and money.

In addition, the medical lobby in the U.S. continues to block legislation that would allow an individual the choice of euthanasia, when it is clear that allowing a patient to suffer in pain, or keep them on artificial life support, is not in their best interest.

The billions of dollars in savings in those two areas alone would pay for the uninsured in this country. Physicians should look in the mirror to see who's to blame.

tracy farnsworth

here you go

Dan Levine

Defensive medicine, inefficient use of ER, unnecessary testing; all contribute to the problem of higher health costs. Notwithstanding that classical economics is out of favor - that is how the problem is best understood. Expanding coverage to the uninsured will increase demand for health care services. Supply of health care providers, hospitals, etc is essentially fixed unless we want to import doctors from the developing world and further deprive those countries of adequate health care. When demand increases and supply is fixed, price (health care costs) will rise. Unless demand is cut from other places. In a New York Times interview on May 3, 2009, President Obama estimated that potentially 80% of the total health care bill goes to chronically ill and end of life care. This topic must be rationally discussed if costs are to be contained. Looking to Medicare savings to pay the cost of expanded care is ridiculous. Obama thinks he can save $500Billion over ten years? Medicare faces unfunded liabilites of $74Trillion. Those savings are a drop in the bucket of where the real problem lies.


He makes no sense. Suppose I have insurance. I walk into an emergency room. Will the emergency room not "(1) evaluate, and (2) make a disposition"? My insured costs should be no more or no less than the uninsured's costs. Now if the uninsured becomes insured, the costs are still exactly the same.


Actually, it costs more to treat an insured person than an uninsured person. If an uninsured person comes in and receives $1000 worth of medical care, it is a $1000 addition to the national cost of health care. If an insured person goes in and receives $1000 of medical care, it increases national health care costs by $1200 since there is the insurance company overhead that has to be paid. When an uninsured person gets treated, the hospital gets less reimbursement, but the care costs the country less.


In addition, immigrants -- legal and otherwise -- consume fewer healthcare services per capita than native-born Americans.
"Per capita" consumption is meaningless. If tens of millions of uninsured are coming here for "free" healthcare, what difference does "per capita" consumption make? No one mentions "per capita" healthcare consumption when we constantly hear the "47 million uninsured" dogma repeated ad naseum as the reason why we need nationalized healthcare.

They are still consuming 10s of billions of dollars of benefits for which they do not pay and to which they are not entitled. And providing even more "free" healthcare will bring millions more over our borders, requiring yet more billions of taxpayer support. The careful parsing of these statistics to make the picture better is not fooling anyone, Jon.

Bobby Sadler

No it's not the uninsured,it's the greed of the Dr's and the insurance companies charging way too much & the hospital's charging way too much. It's a circle of greed. It stops at us the people blue collar worker's. We pay the high prices.


Hello from another healthcare provider in your community in western Kentucky. While the analysis is correct as far as it goes, it is incomplete. The uninsured are one piece of a very complex puzzle. For a good comprehensive blog post on this topic, try http://www.dailykos.com/story/2009/9/11/768474/-Breaking-Through-Public-Option-Nonsense
While it focuses on the public option aspect, it covers a lot of other territory. Yes, dailyKos is a liberal blog site, but this post is primarily a critique of the Left's positioning from someone on the Left, hence it is quite constructive. Nonsense on the Right is not addressed, but acknowledged.

This is a complex problem, and unfortunately in America we have been trained to process things through simple storylines with clear villains (e.g. illegal immigrants! Big Pharma! Big Lobbyists! Big Government! etc) and heroes that do not reflect reality. All those villains are red herrings and do not advance productive dialogue.

Barbara Stone

Why is it never mentioned that citizens of the
US shoud be doing all they can to prevent illnesses.
There should be a huge campaign, to promote good nutrition,
stop smoking, stop drugging and abusing etoh. It's a disgrace to see the huge amounts of drugs that are getting into this country destroying the lives of millions of our families. Another disgrace is the amount of pollution in this country. Prevention should be the main focus we should be working on.

larry wilkins



I'm retired (took early retirement at age 62 because of some health problems that escalated due to job stress) and my SS check is $649 per month. I've tried to get health insurance and the cheapest premium I was offered was $740 per month. I have to wait until I'm 65 for Medicare to get any kind of health insurance at all. Do the math, I'm sunk.

So, there is one option left that I can do, as long as I am physically able.....the bullet is already in the chamber.



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