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1 minute ER ‘exam’ results in $2,000 bill


John Marshall came in from the John’s Island golf course to wait out a thunderstorm in the clubhouse. Resting his arm on the bar, he noticed a strange sensation – his elbow “felt like a waterbed.” A swelling he describes as “a baseball at the end of my arm” had popped up seemingly out of nowhere.

At 8 a.m. the next day, Marshall, a Dartmouth-educated fitness buff recently retired from Wall Street, headed for Cleveland Clinic Indian River’s emergency room. After an exam he says took “literally under a minute,” he left with a diagnosis that confirmed his suspicion – bursitis – a referral to an orthopedist and a debt to Cleveland Clinic of $2,000.

Marshall, who turns 62 next month, gave up his excellent employer-provided insurance when he retired as head of marketing for an asset management firm. Current insurance for him and his wife costs $25,000 a year in premiums, with a $5,685 deductible for each of them, which neither has met. That meant the two grand incurred in those few minutes at the Indian River’s ER would have to come out of his pocket.

“I was apoplectic,” he said. “Poor people don’t pay; we subsidize that. The people who get screwed are like me. I’m retired and I have this crummy insurance. This is completely demented.”

The high deductible on Marshall’s policy isn’t a secret. It is printed on his Connecticare insurance card.

That should have been a red flag at the ER, Marshall insists. It should have prompted check-in staff to suggest urgent care as an alternative.

“The elbow never bothered me in terms of hurting, other than I looked like a freak,” Marshall said. He went to the ER chiefly because the elbow was warm to the touch and he feared infection.

“All it would have taken is, ‘You have a high deductible policy and this is going to be quite expensive.’ That’s all it would have taken. I would have gone, ‘Oh, OK, have a nice day.’”

He also felt someone should have discussed how much his treatment would cost.

But a federal law known as EMTALA keeps hospitals from talking about finances for fear of deterring a patient whose health is in serious jeopardy. EMTALA requires all hospitals to stabilize patients in true emergencies regardless of their ability to pay.

The law intended to safeguard those without means in need of treatment ended up shielding Marshall from learning in advance how much his visit would cost.

“Patients that present to the emergency room . . . are assessed by medical personnel in the triage area,” said Angela Dickens, Cleveland Clinic Indian River marketing director when asked about the $2,000 for such a brief and apparently inconsequential visit.

“Per EMTALA, patients are never turned away and are not asked about insurance status until full registration occurs. If a patient chooses to be seen by a provider after the medical screening exam is performed, additional charges are incurred.”

The hospital portion of Marshall’s bill, not including the physician’s fee, was $1,227. That included $800 for the “medical assessment exam” he doesn’t remember getting, upgraded to include seeing a physician that he supposedly “chose” to see – he doesn’t recall be given any choice.

Marshall said the only “screening” he encountered was “the check-in woman who took my [insurance] card and asked what I was there for.” The only physician he saw was the woman who “casually glanced at me and said, ‘Bursitis.’”

“In the course of looking at her clipboard, she said, ‘You don’t have an infection.’”

When Marshall asked if she could aspirate the giant lump, the physician said, “We don’t do that here,” referring him to an orthopedist.

As for that ER physician’s fee, the bill, for another $800, would come from Envision, the company that staffs Cleveland Clinic Indian River’s ER.

The hospital’s pricing has not changed since Cleveland Clinic took over Indian River Medical Center in January, according to Dickens.

Whether Marshall’s bursitis constituted a true medical emergency was never discussed when he arrived at the ER. He was familiar with the condition, but it was the mention of infection on consumer medical websites that propelled him to seek treatment. Infection, the sites said, was a serious complication that could lead to permanent damage of the joint.

If that triggered alarm in Marshall, it would be understandable. Fifteen years ago, he was hospitalized with a systemic staph infection that started from an abrasion on his arm after he wiped out on his road bike. The night he was admitted, his nurse had told him, “This is serious. You could lose your arm.”

A doctor who saw him at that time called the infection life-threatening.

“I took the infection thing seriously,” Marshall said.

Marshall was acting on the same instinct – fear – as thousands of indigent patients showing up at ERs with what turn out to be non-emergency complaints. In a much-publicized debate, not only in Indian River County but nationwide, those poor patients are blamed for “clogging up” the ER, to use the phrase of Indian River hospital executives, who have tried multiple programs to steer non-emergency patients elsewhere.

Marshall, who could easily afford the care of his choice, didn’t think to go to an urgent care center. He doesn’t have a primary care doctor, not here and not in Connecticut where he spends the summer. Somehow the national trend of high bills at hospital ERs had slipped his notice.

“I just feel so stupid that I subjected myself to this needlessly. But it’s an indictment of the system that I wasn’t aware of this,” said Marshall. “Maybe I was living in a bubble.”

After multiple calls, Cleveland Clinic Indian River’s billing department offered Marshall a payment plan – $51 a month. Or, if he wanted to pay his $2,000 off in a lump sum, they would offer a 5 percent discount. He is weighing his options.

“I think the charge should be nothing,” Marshall said. “It was a cursory glance. Is that worth $2,000?”

As for his elbow, it took about three weeks for the inflammation to go down. That’s a week longer than the orthopedist predicted. He, too, did not aspirate the fluid from the lump, fearing an opening for infection. He did, however, order an X-ray that confirmed the diagnosis.

Total bill: $276. “At least he did an X-ray,” says Marshall.