A Tale of Cost and Care: Blood on the Sidewalk

By Margaret Cary, MD, MBA, MPH | Published 8/17/2019 17

cost and care close up ambulance

Photo source: Wikimedia Commons

Going to the gym in the morning is one of those things I do because it’s good for me and I feel better afterward. That doesn’t change my lack of enthusiasm. I get up early, put on my work-out clothes, and then start writing, delaying my gym visit as long as possible.

One morning, my trip to the gym was over icy sidewalks, so I walked carefully on the strip of grass between the sidewalk and the street, which was a little less slippery. I calculated that I had just enough time to get to the gym, get my heart rate up for 30 minutes, and get back to my next call.

A block from my house, I saw a young woman kneeling on the sidewalk. Two policemen hovered nearby as if to protect her. She wore a red coat, her red hat upside down about two feet away from her. As I got closer, I noticed blood on the sidewalk.

A teaspoon of blood looks like a quart, and this was more than a teaspoon. The young woman covered her face with bloodied hands.

Is there anything I can do?

Once I finally head to the gym, I am reluctant to stop for anything—that’s my way to get it over with. I grappled for a moment with the temptation to just keep going and get the miserable half-hour out of the way, but I finally did what my medical training compels me to do. I stopped.

Is there anything I can do?” I asked, identifying myself as a doctor.

I’ve called an ambulance,” the officer told me.

The woman started talking through her blood-covered hand, eyes red and damp. I sat next to her, eye-to-eye, and put my hand on her shoulder. My one-cotton-layer-covered butt settled on the sidewalk ice.

What happened?

I fell and broke my tooth.”

May I take a look? I used to work in an emergency department in a ski resort.”

Thinking like a doctor, coach and policy wonk

I asked her to open her mouth and she dropped her hand. She looked like a horror movie escapee. Blood was everywhere—head and lip wounds bled profusely—and her right front incisor was about half gone. She might need sutures, depending upon what happened behind her lower lip. Later, she’ll need a dentist to determine what to do about the injured tooth.

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My linear-thinking, differential-diagnosis, medical-school-trained, quick-assessment self-knew she was mostly just scared. She didn’t really need an ambulance. My coach trained self-listened to her story. My health-policy-trained self-wondered about her insurance.

I was torn between annoyance and ecstasy at having my workout cut short. What a great excuse to avoid the gym.

Is there anyone you can call?

I’ll call my boss,” she said. “She’ll come to the hospital for me.”

An ambulance was called

Fortunately, she was covered by her parents’ insurance policy, which was with a reputable company. Her insurance would most likely cover the emergency department visit, but it might not cover an ambulance ride. If the insurance company decides later, when they get the bill, that the ambulance wasn’t necessary, it could deny the claim—it doesn’t matter that the police called the ambulance and put her in it. That’s most likely a hit of a $1,000 or more.

She didn’t have to take the service just because the police suggested it. She could take a cab or call a friend. For that matter, she could say, “No, thanks,” and walk away, if she felt up to it.

Two taxis passed us on the street.

Do you have Uber?” I asked.

She didn’t.

Had the policemen not been there, I would have encouraged her to just call her boss to take her to the ER. She would have been fine. But she seemed pretty shaky and the EMT unit had already been called. I decided not to push the issue.

The nearest fire station, with the EMT units, was only about five minutes away. When it comes to hospitals, you never know which one they’ll take you to. A few years back, a DC ambulance driver was at the end of her shift when she picked up an unconscious man. She assumed he was just drunk and dropped him at a hospital close to her house, instead of the nearest one. It turned out that he had been whacked over the head in a mugging during an after-dinner walk. He died from the head injury.

The case only made the news because the man happened to be a prominent journalist – a sad commentary on our system.

Cost and care 

This woman wasn’t going to die, but what hospital she would end up at was a crapshoot. It had nothing to do with what her insurance would cover. Even if the hospital was on her health plan, the emergency room physician might not be.

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The plastic surgeon, the ER would likely call, might or might not be a preferred provider with the insurance company’s negotiated rate. I doubted that she had the provider list in her pocket. Also, the ER would probably just contact whoever was on call. Was she supposed to ask them to look up her company’s provider list? Decline the care? I could only hope that she would have the presence of mind to ask the right questions before she ran up a bill that would bankrupt her.

ADD_THIS_TEXT
 

Too many people end up like that woman, getting random treatment because they either can’t speak for themselves or don’t ask the right questions.

There’s so much to think about when you’re injured, in pain, and distressed. What if you’re comatose? In another city? Don’t have anyone to run interference, as I tried to do? Any passer-by can step in, can be present, for an injured person. However, once the authorities arrive, that opportunity is gone. The police only let me help because my MD degree gave me credibility and confidence.

By the time an ambulance showed up about 20 minutes later, I knew I could feel entirely justified in skipping the gym. I shared what I knew with the paramedics, who guided the injured woman into the back of the ambulance. They would clean up the blood and assess the injury. I suggested the closest hospital, which I was pretty sure her policy covered.

Replaying the story

I pushed the lazy demon off my shoulder and hauled myself to the gym, anyway. As I shuffled the day’s schedule to accommodate an abbreviated workout, I told the desk attendant the whole story.

On the elliptical, my brain had replayed that woman’s morning. There were so many moving pieces. Everyone followed the rules. The police called professional help, and the in-the-moment handoff to the kind EMT went smoothly. I tried to provide comfort by sitting down to talk to her and touching her to help her feel less alone. I hope that helped. Still, the whole experience bothered me.

Everyone did their job that morning. But that woman may just be starting a long battle with her insurance company. The desk attendant who heard me out just shook his head, baffled, as I unloaded my frustration on him.

I’m from Germany,” he said. “We don’t have these problems.”

***

 

Published on 2/18/15. Updated 8/17/19.

Margaret Cary, MD, MBA, MPH

Website: https://thecarygroupglobal.com/

Margaret Cary, MD, MBA, MPH AKA Dr. Maggi, graduated from the University of California, Santa Barbara with a degree in zoology and a minor in polo. She exercised up to 23 polo ponies/day to put herself through college. Her MD is from Baylor College of Medicine, her Master’s in Public Health (MPH) from UCLA, and her Master’s in Business Administration from the University of Colorado, Denver. She completed her Family Medicine residency in Santa Rosa, through UCSF.

From an emergency room physician in a ski resort, Dr. Maggi has worked in nearly every aspect of health care, landing at her current post as CEO of The Cary Group Global. The Cary Group Global provides executive and leadership coaching and consulting to executives in health care and film and television production.

Dr. Maggi graduated from Georgetown University’s Leadership Coaching program and holds a Professional Certified Coach (PCC) credential from the International Coach Federation. Her clients include

• Mayo Clinic,

• AMIA (American Medical Informatics Association),

• University of Massachusetts Medical School,

• Bon Secours Health System,

• Yale School of Medicine

• Weill Cornell College of Medicine,

• Georgetown University School of Medicine,

• Dubai Medical College,

• and other academic medical centers and research organizations.

Dr. Maggi is an expert at facilitating others’ learning, from medical students to health system CEOs. Her client base consists of C-suite executives to VPs and department chairs, both new and experienced. She developed and led the Community of Champions, the national physician leadership development initiative at the Veterans Health Administration.

She has held many executive posts and practiced medicine in Santa Rosa and Mammoth Lakes, California; Denver, Colorado; London; and Kendal, UK.

Her research for Telemedicine and Telehealth: Principles, Policies, Performance, and Pitfalls (The Lancet’s review) led her to the realization it’s all about the people, the relationships, and asking questions. Her passion project is A Whole New Doctor, a leadership development and coaching program for medical students, staffed entirely with volunteers. A Whole New Doctor serves medical students from Georgetown University School of Medicine, Penn State College of Medicine, University of Nevada, Las Vegas School of Medicine, University of Virginia School of Medicine, Howard University College of Medicine and Hofstra Northwell School of Medicine.

Dr. Maggi is adjunct faculty at Georgetown University School of Medicine and has taught at the Harvard Macy Institute. She coaches TED Fellows and Global Good Fund Fellows and leads nonfiction writing workshops.

In addition to being a contributing author for The Doctor Weighs In, Dr. Cary also serves on the TDWI Editorial Board, where she medically reviews articles submitted for publication.

She is intellectually curious about nearly everything, a lifelong learner, animal lover, gardener, and always ready for adventure.

Comments:

  • Excellent read. I’m making the decision on whether to help pretty often as well. I could completely relate to that component of your story.

    The line “I’m from Germany, … We don’t have these problems.” reminded me of my own recent experience with US insurance and “retail” medicine.

    I was reviewing a web site that described a patient with an exercise-related soft-tissue complaint. It could have been a pharma site, or a payer or provider site, or simply ad-driven revenue information resource. The bottom line was that it steered the patient to seeing an orthopedic sports physician who was in network, or cost efficient, or part of the well-branded local healthcare conglomerate. It offered an estimated cost of $200 and offered to schedule the appointment within any provided zip code.

    My reaction, (I am like you, with practice experience, board certification, and compassion) was, “I’m apparently from another country as well, how about rest, ice, ibuprofen, or even just pharmacy-based minute-clinic at less than a quarter of the predicted cost of an orthopedist ?

    Getting a good, unbiased diagnostic opinion is still too hard and unpredictable in every country I’m familiar with, although for different reasons and contexts.

    Thanks again for writing this terrific piece.

    • Thank you, Joe – As always, your comments are on point. Thank you.

    • Thank you, Marc. I may be in your general area in September.

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