Yeah, we've know for a while now that narcotics on the whole aren't great for chronic pain - ESPECIALLY if we're talking musculoskeletal stuff. OTOH, if I get pancreatic cancer I'll hopefully be in a percocet haze until I pass on.

As I referenced in my tl/dr above, a lot of our narcotic issues lie from plain bad medicine espoused in the 1980's for mostly good intentioned reasons. This seems to be changing pretty rapidly, especially among younger docs. In a cold blooded sense, things well get better when doctors and patients of my cohort shuffle off into the great beyond.

The point about death by liver failure (for tylenol) or kidney failure (for motrin/NSAIDS) I initially shrugged at - but the more I thought about it - might be a problem. AFAIK there are no good studies on either in terms of months/years of use. We're born with a LOT of excess liver and kidney function, and the liver is pretty amazing in terms of fixing/regenerating itself - but I think it's entirely possible (especially for a subset of patients that for some reason would be more susceptible to it) that you could run into problems. We'll see. It's amazing how little we know about how pain works.

MM MD

It's more of an object lesson in how a simple tweak in regulations can solve a problem. Disallow any amount over a fixed percentage of, say, Medicare for services, or allow x + 10% for out of network charges. It's not necessarily a bad thing for people to stay in network given our fragmented health care system - EMR's don't "talk" to one another, you're better off at a hospital where your doc/specialist works, all things considered. (And yeah, I get in a perfect world none of this would be an issue - the point is that this is a very strange/atypical way to do business by Zuck's namesake) As the article noted, hospitals rarely (I would have said never) do this. Strange.

Negotiations with insurers can get tricky - my group got into a go-round with a company who's name rhymes with Broo Kros who negotiated by saying they would pay only x - which was about 30% less that our home HMO with whom we have an agreement that we will give a preferred (best) rate to - which put us in a bind because we also agree as part of our agreement that we'll contract with ANY insurer. Since doing both would have logically ended up in us being paid less than nothing, we ended up not contracting with them with out hospital's consent. (They actually just agreed to table the issue until we got to a solution) We eventually worked it out, but it was a pain in the ass. Dunno if something like that was going on in the article, but it seems possible.

Good news and bad news on the trauma front - if you're fairly ****ed up you're headed for a trauma center. The good news is that you'll get pretty good care - trauma is something US health care is pretty good at, for reasons that should be obvious. The bad news is that it's REALLY expensive. In Nevada (every state varies slightly, but not by much), trauma criteria are set by the State - there's a big meeting every couple of years where the metrics are set. We have three levels - green, yellow, and red. You get slotted depending on mechanism of injury, vital signs and type on injury. Stabbed in the chest/belly - red - $25K or so. Open femur fracture - yellow, 17K - Hit a deer on your Harley, neck pain with good vitals - green, 9K

This is all before I say hello. The money goes to the state system and gets redistributed to the trauma centers so they can have the lights on and me, a trauma surgeon, a gaspasser and whoever else we need to take care of Pokey after he gets his ass shanked by Leon at 3am because Pokey stole Leon's Ipod. Since Pokey has no insurance for his 100K plus bowel resection/colostome/wound infection/liver packing/chest tube, the cost gets shift to the insured motorcyclist who smacks Bambi and breaks his femur. My bill, the hospital bill and everyone else's is added to that. Gets pricey.

MM MD

You’re one of the good ones, I was thinking of Dr. Ikes and that eye doctor who’s always bitching about needing more money.

Because of the way the CBO scores what is "federal" vs what is "private" spending, almost any progressive changes to the ACA or healthcare, not just Medicare for All, is going to be scored as "nationalizing" healthcare and cause the CBO to show massive increases to the federal budget

https://www.peoplespolicyproject.org...tionalization/

Vox dives in to the insanity that is emergency room billing: https://www.vox.com/policy-and-polit...neral-hospital

It is unusual for a hospital to be fully out-of-network:

But in San Francisco, it can be hard to avoid if you find yourself in an ambulance:

While the issue of a hospital being out of network is uncommon, it's actually a lot more common to find your hospital visit to include an encounter with a doctor who is out of network, often with you having no way of knowing that until you're hit with a massive bill that your insurance won't cover:

Sarah Kliff (the author) expanded on that on The Weeds - you might get an X-ray reviewed by a radiologist, who you never speak to and have no way of knowing about, who's out of your network and thus costs you a ton of money.

I stumbled upon this piece because it was about San Francisco, but she also wrote a more general piece about ER billing in I read 1,182 emergency room bills this year. Here’s what I learned.

For the anti-Obamacare "Government shouldn't force me to buy anything crowd", what is the justification for something like this?

You could go unconscious and wake up to many tens of thousands of dollars worth of medical treatments that you did not consent to. Why can you not just say "I didn't authorize that purchase"?

I'm gonna need to be unconscious to get taken by ambulance to an ER. Is there a bracelet you can wear which says what ER to take you to?

Wait, if the hospital and your insurance company disagree about what amount is fair, the hospital bills you for the difference and you're completely ****ed? Wtf?

If you're out of network, yes.

JFC. I'm reading up on it right now. I guess it's called balance billing. It's illegal in some states and in basically any country that's not a complete joke.

This is so enraging. Oh, well, see we ran some tests and uh, it turns out you owe us eleventy thousand dollars because **** you that's why, good luck in court, sorry about your accident. What a disgrace.

Being a Canadian, it’s like you guys are speaking a completely foreign language.

Same. Like not talking about the fact that we have public healthcare, but I have private coverage and the idea that I would get a 20K bill due to some argument between the hospital and insurer is a joke. I can go to any hospital I like in Australia, public or private, and be covered. I have co-payments to make, but they're capped at 10 days of $50 a day (and could be less if I wanted to pay higher premiums).

The debate usually centers around the lack of public healthcare in America, but it's worth noting that private coverage also frequently sucks, and that this is due to 1) spineless regulation and 2) the employer coverage system, which adds a layer between customer and insurer which makes it harder to customers to reject bad deals.

If this isn't a thing, soon it will be I'd say. Too much $ not to.

Yeah US healthcare is a total joke; too many places/drug companies/etc are just in it for the $ gouging. They all lobby politicians so good luck getting anything done there.

Doesn't help a lot of rural hospitals close because they are losing money, certainly some of which is treating uninsured who never pay them.

I just love the fact that deductibles use calender years instead of trailing 12-month totals to determine how much you pay. Really awesome that I both broke my nose in December and was diagnosed with a torn ligament in my thumb, both of which required surgery, but am almost certainly going to end up paying thousands of dollars extra because the hand surgeon couldn't fit me in until the first week of January instead of the last week of December. Also, as a first-time opioid user over these past few days, these things are totally not worth ruining your life over. Virtually a nonexistent buzz and my thumb still hurts, this is bull****

Which opioid?

Edit: I ask because hydrocodone and codeine are both activated by metabolism in the liver and it's quite common for people to genetically have poorly functioning versions of these enzymes. For these people, hydrocodone/codeine work poorly or not at all.

If it's oxy, I can only recommend you just keep taking more and more. Maybe crush it up and snort it if that's not working, if that's also not doing the trick, consult your local fentanyl dealer.

5mg oxycodone, been taking them every four hours for the last two days. I'm sure my thumb would hurt more if I stopped taking them, but even though my fingers aren't in the cast at all, just my thumb, it starts aching if I type for more than a few minutes straight

Yeah ok, sucks. Guess you just don't respond that well to it.

In most states, there is something called a prudent layperson statute, which states that if a reasonable layperson could have thought that they had a health care emergency and present to an Emergency Department for treatment, the insurer must cover the bill, or at least a substantial portion of it (laws are different from state to state) Some states mandate that the maximum you can balance bill for is some percentage above medicare, which seems reasonable, more or less.

This **** is important because frequently I can't tell if, say, your belly pain is from an acute appendicitis or acute Taco Bellitis without labs, scans and whatnot. The workup for the two problems is pretty much identical, but in one case I send you to the OR, and in the other I send you home and suggest avoiding the Fire Sauce next time.

Some skeevy insurers try to stick the patient with the bill if their workup is negative. That's wrong, and unfair.

It gets more complicated if you need to be admitted. Then, if you're covered somewhere else we'll usually transfer you if we think you're stable - and we routinely transfer people from Reno to the Bay area if they have Kaiser insurance - they're notorious for wanting their patients at their facility, but they've always been reasonable when I've had discussions with them. Some other insurers, (skeevy) may use this as an excuse to screw the patient.

As I've noted before, this arm fracture/Zuckerberg hospital thing is VERY odd. I suspect (hope) that there is more to the story then we're seeing - that's very strange behavior from any hospital.

MM MD

Hand injuries are notoriously painful ( I tell my patients that the three most sensitive spots in the body are the tongue, the fingers, and somewhere else you don't want cut/twisted/bended.) Pound the ibuprofen or naprosyn, and use the narcs as a spacer drug. It's gonna hurt until you get it fixed.

And yeah, the yearly deductible is crazy - we're always crazy busy the last two weeks of the year with people coming in with chronic/near chronic problems they want dealt with before Jan 1st.

MM MD

I try to cram all my medical needs into odd years. Great system we've got here!

When it comes to any of the medications, one often receives a generic. My experience across the past two and a half years (almost) saw me finally get prescribed Percocet for the back pain stemming from an accident where I got hit by a large fire truck. A couple of the India-based manufacturers of the generic 10mg Percocet had product that was not worth a damn, while the Malinkrodt (sp?) is far more effective, at least for me. Your pharmacist should be willing to discuss who the manufacturer was for the generics if you are getting generic oxy (or any other meds).

My day starts with two of those, which gets me through enough of the workday before the pain returns.

All of my care is out of pocket since there is nothing affordable about policies post-ACA. So, I spend about $180 for the office visit each quarter and I use GoodRX to compare prices on the Percocet. Vicodin would be cheaper, but it does absolutely nothing for me in terms of the pain...and I am not trying to take the meds for a buzz. The saving grace for me with the Percocet is that I don't have a propensity towards addictions...

Principled Libertarian Rand Paul is off to socialist hellhole (Canada) for upcoming hernia surgery. I present this information without comment, other than NICE ****ING JOB AT ELECTING SENATORS KENTUCKY

I found it amusing that Rand Paul's people were falling all over themselves to assure the American people that he was being treated at a private facility costing tens of thousands of dollars that only wealthy people could afford.

Infuriating:

https://www.newyorker.com/magazine/2...histle-blowing

I knew there was lots of Medicare fraud happening, and I suspected Medicare Advantage of being terrible, but holy ****.

This ****ing country, man. Just a straight up kleptocracy.

The power of investigative journalism: After Sarah Kliff's reporting, Zuckerberg San Francisco General is changing its practices and will start accepting private insurance