Former Surgeon General's Exorbitant ED Bill: Impact of 'Cover Your Ass' Care

— Jerome Adams, MD, MPH, sits down with app to discuss his recent $10,000 ED bill

  • author['full_name']

    Jeremy Faust is editor-in-chief of app, an emergency medicine physician at Brigham and Women's Hospital in Boston, and a public health researcher. He is author of the Substack column Inside Medicine.

  • author['full_name']

    Emily Hutto is an Associate Video Producer & Editor for app. She is based in Manhattan.

In this exclusive video interview, Jeremy Faust, MD, editor-in-chief of app, and Jerome Adams, MD, MPH, discuss Adams' recent emergency department (ED) bill and the many factors that can lead to a patient's "financial ruin."

Adams was the 20th U.S. Surgeon General and is currently the director of health equity at Purdue University in West Lafayette, Indiana.

The following is a transcript of their remarks:

Faust: Hello, it's Jeremy Faust, medical editor-in-chief of app. I'm so happy to be joined by Dr. Jerome Adams, MD, MPH. Dr. Adams is the director of health equity at Purdue University, and he was the 20th Surgeon General of the United States.

Dr. Jerome Adams, thank you so much for joining us.

Adams: Hey, it's great to be with you today. I wish it was to talk about a more pleasant subject, though.

Faust: Right? But it's always good when we have someone of your expertise experience something that actually a lot of people can relate to, unfortunately. And I think that's why your article in app is so resonant.

I'll just say the title. It's called "I'm a Former Surgeon General and I Couldn't Believe My $10,000 Medical Bill: Everyone must be able to access necessary care without fear of financial ruin." Hear, hear!

For those who haven't read it, tell us the story. What happened?

Adams: Well, believe it or not, I was in Scottsdale, Arizona for the Society of Critical Care Medicine meeting, a meeting of clinicians. And like many people who go to Scottsdale, Arizona, I had some free time and I said, "I want to go for a hike." There was a mountain there called Camelback Mountain that many of our viewers and listeners will know about. It's a nice little hike; it takes you about 2 hours. I did the hike, came back down, was feeling fine and actually went out to dinner. When I was out at dinner, I started to get lightheaded and dizzy.

I'm cutting to the chase here, but they literally have hundreds if not thousands of emergency admissions in Scottsdale, Arizona, every year because people hike up Camelback Mountain in the desert, hit the midday heat, don't drink enough water, and get dehydrated.

So I ended up in the emergency room and I got a couple of bags of IV fluid. I got two rounds of blood tests to confirm that I was dehydrated. They wanted to look at my BUN and creatinine, they checked my troponins to make sure I wasn't having a heart attack, and they discharged me from the hospital.

About 6 weeks later, I got a bill for $10,000, which my insurance negotiated down to about $5,000. And because I'm in a high deductible health plan, I was responsible for $5,000 for a couple bags of IV fluid.

Faust: Which is something that not everybody can afford.

Now, one thing I will say is that people will hear that story and they may say things like, "Oh, look at those doctors. Why are they running all these tests on this healthy man of a certain age?" You're not an old man, but you're a healthy guy who shouldn't necessarily need all these tests. Why would they do that?

I'll just speak as an emergency doctor: Yes, 90% of the time when somebody comes in with what you're talking about, it's dehydration and you need some fluids and we're just going to check that your kidneys aren't too dry. But let me tell you, folks who are not ER docs, we have to think about: what if the heat and the dehydration actually tipped this patient into a cardiac event or unveiled an underlying problem? Because maybe this shouldn't have happened.

So for people saying, "Oh, why would they do all these tests?" I would say, let me tell you as an ER doctor, because we have to think about what also could be going on, and then maybe it's more than one thing. So first off, all these tests sound like a lot, but it's kind of reasonable.

Adams: Yeah. And you raise a great point. What's interesting is when I first put out the tweet, a lot of emergency medicine docs really responded negatively to the tweet because they thought I was attacking the care. I got great, and I think appropriate, care from the emergency medicine team that took care of me. And I completely understand why. I turned 50 this year -- you want to rule out a heart attack, you want to rule out a stroke, you don't want to assume.

But I think it brings up a couple of key points. Number one, we have a medical legal system here which puts us in a situation where if you miss that one in 10,000, you could lose your medical license, right? That's a reality that doesn't exist anywhere else in the world.

Even when you provide appropriate care, it's often care where the cost is much more than what it would be [somewhere else]. I could have this exact same scenario in Switzerland or in the U.K. or in many other countries in the world, and my bill would not be anywhere near to what it was. So it's not just about the testing that was done, it's about the cost of the testing that's done.

It's about the broader medical legal environment that sometimes does cause us to -- we call it CYA, I don't know if we can say it on tape, but "Cover Your Ass." There are tests that sometimes we order because you don't want to miss that one in 10,000 rarity. Not just because you want to take care of the patient, but also because, again, you could lose your license if you end up in a situation where you miss something.

Faust: We have a medical audience, so I like to dive into this.

I'll have a patient come in who has a "mechanical fall". They twisted their ankle and they fell. But then they're like, why am I getting more tests? Because actually I'm saying, "Wait a second, you take that walk every day of your life. Why today?" I always say that on cross examination or on redirect, they did admit to me that they'd been feeling short of breath before, or they say, "Oh you know what, I've been having a little trouble going to the bathroom." So the mechanical fall is actually a kind of downstream effect of a medical problem.

This kind of stuff is a little bit of CYA, I'll acknowledge that. I do think about that and how I document. But some of it is actually just making sure that I'm not being misled by raw probability. Ninety of the time, a mechanical fall is a mechanical fall. Ninety of the time, dehydration is dehydration. But maybe 5%, 10% of the time, it's something else. Is that something medically important?

So that's how we get in these situations. But to your point, that doesn't mean it has to be literally a financially ruinous occurrence for many, many people.

Adams: Exactly. I'm going to give you a real, concrete example.

There was only one test that I got -- and I'm a critical care doctor -- where I was like, "Why are we doing this?" And we're talking to a medical crowd here -- why am I getting a chest x-ray 10 hours after I've been in the ED after we've already confirmed with lab tests that this is dehydration, after I've responded to fluids, after I've gotten a negative EKG? That's the only thing that I questioned.

But that said, the problem wasn't the testing that was done, it was the fact that I got a comprehensive metabolic panel. The average cost in the Scottsdale area for a comprehensive metabolic panel is about $40, and I was charged $374 for that comprehensive metabolic panel. Far more than what is a reasonable price, in my opinion.

That's what led to the bill. It wasn't the care that I received or even the number of tests.

Faust: And this is so interesting, because I know that a chest x-ray is part of that protocol. And I'll tell you, one of the reasons that that chest x-ray gets done is both reasons we discussed. One is like, could this be a weird cardiomyopathy? And maybe we'll see that they've got an enlarged heart silhouette. But a lot of times it's actually because of that CYA.

I've seen these cases -- and I do like to read a little bit of medical malpractice literature -- there was one where someone who needed a chest x-ray didn't get it. And I'll never forget this, the lawyer tore apart the doctor. They said, "Well, wait a minute. Isn't that chest x-ray standard protocol for a chest pain workup?"

And he says, "Yeah, it's standard."

"Oh, you think you're smarter than the protocol? How come?"

And then they get into this thing where the jury's like, "Oh, this doctor's arrogant."

So that's where the CYA comes in, is there.