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Can the ER legally test me for drugs without telling me and without my consent?
April 4, 2011 3:11 PM   Subscribe

Can the ER legally test me for drugs without telling me and without my consent?

Recently I went to the ER, after having cold/flu-like symptoms that lasted a few weeks, because I was feeling woozy and concerned that I might have some more serious infection.

I signed a generic consent for treatment, and the only tests that were orally discussed (and which I consented to) were an x-ray and blood screen for infections.

When I got the invoice, though, I found out that they also tested me for amphetamines, barbituates, benzodiazepines, cocaine, ethanol, opiates, & phencyclidines. Total bill to insurance $1050, amount of that I had to pay $78.75.

I was never told that they would be doing drug screening, I did not consent, I don't believe it was medically necessary, and in fact I very strongly object to this having been done (and my having to pay for it).

This is an interesting article on the topic, which cites this research paper showing that such testing has no effect on patient treatment or outcome in psych-ward ERs. (To be clear, I walked in to the regular ER.)

The research paper supports my contention that the tests were not medically necessary, since "no effect on treatment / outcome" = "pointless".


So the question:

Is this legal, and how can I, at the least, force the hospital to remove these charges from my bill?

Insurance says that they won't contest it, and I have to take it up with the hospital. The hospital obviously has conflict of interest in reviewing its own decisions, and isn't going to admit to doing something unethical and unnecessary.

So I'm not sure where to go from here.
posted by saizai to Law & Government (58 answers total) 6 users marked this as a favorite
 
Talk to the hospital. Yeah, they have a conflict of interest...but they usually have someone overseeing messes like this so it doesn't happen over and over again leading to the likelihood of a lawsuit.

I think its pretty likely that paperwork was messed up and they put your blood through for the wrong tests.

Did you ever get the results for ALL the correct tests? If you were tested for stuff you didn't know about...I'm wondering if the tests you WERE to receive were even done. THAT might be a bigger issue...they might have given you a meth test...but didn't test your potassium or iron levels. That would be a big problem for the hospital (and potentially, your health).
posted by hal_c_on at 3:16 PM on April 4, 2011 [1 favorite]


saizai: "I signed a generic consent for treatment..."

What does the consent form you signed actually say? Do you have a copy? If you don't, get one before you do anything else.
posted by DarlingBri at 3:17 PM on April 4, 2011


Short answer: Yes.

Long(er) answer: They do this as a CYA measure in case they prescribe you anything that might have interactions, and to make sure that you're not OD'ing on something. It was almost certainly covered in your generic consent. Anytime you have blood drawn in an emergent situation, you can assume that they will run a full panel.
posted by charmcityblues at 3:20 PM on April 4, 2011 [8 favorites]


which cites this research paper showing that such testing has no effect on patient treatment or outcome in psych-ward ERs. (To be clear, I walked in to the regular ER.)

But you weren't in a psych ward and were not presenting with psych symptoms so that research does not support your contention.

And it could be argued that feeling woozy is a possibly symptom of drug use so they have reason to rule it out (how true that is I don't know, but the argument could certainly be made). I had a pregnancy test done when I went to the ER with vomiting even though I told them several times it was not possible for me to be pregnant, because that's one possible cause of the symptoms and they needed to rule it out before deciding on my treatment. They didn't bother telling me, I overheard them talking about it. And as annoying as this stuff is, it's much less annoying than them missing something important and hurting you by accident.

Definitely check your consent form, because it's highly likely you agreed to let them do any blood test they deemed medically necessary (which this could very well be). That's where you'll need to start if you're going to argue the case anyway, so might as well take a look.
posted by shelleycat at 3:59 PM on April 4, 2011 [1 favorite]


I can see how this could be upsetting but I would let it go. Write a letter if it will make you feel better. I work in a hospital and I can almost guarantee that the "generic consent" you signed covered a drug screen.

There are good reasons for doing this, just as the TIME article states.
posted by Fairchild at 4:06 PM on April 4, 2011


My wife, a registered nurse, would be the first to tell you that those tests are not a case of anybody trying to invade your privacy or doing anything supurflous.

If you're in bad enough shape to have to go to the ER for symptoms like you describe the difference between the staff having this information and not knowing can literally mean the difference between life and death (or at least a sea or serious misery) for you.

She's been aroiund as a nurse for 24 years and could tell you some very sad stories.
posted by imjustsaying at 4:12 PM on April 4, 2011 [2 favorites]


You gave blood for tests. A little blood only goes so far. The blood was allocated for certain tests. Were those tests done ALONG with the drug tests...or were the drug tests done INSTEAD of those tests?

THAT is the main question you should be asking the hospital. Their ears will perk the hell up when you ask that.
posted by hal_c_on at 4:16 PM on April 4, 2011 [3 favorites]


hal_c_on: They didn't give me results of anything, just told me orally that I tested clean for infections and gave me a saline IV.

I'm going to do a HIPAA full records request later this week which ought to catch this.

DarlingBri: I don't have a copy. It was generic, to the effect of "we can perform treatment that is necessary". However I think that my rights to informed consent could not be waived by such a generic treatment contract.

shellycat: If anything it makes a stronger case. I wasn't presenting with psych symptoms (other than being somewhat "out of it"), and I was completely able to render informed consent for my care. They deliberately chose not to tell or ask me about this screening.

imjustsaying: That's nice, but it doesn't relieve their obligation to operate under informed consent rules, or to at the very least tell me that they are doing the drug screening without my consent because they think that I would lie to them and that it's medically necessary for them to know.

hal_c_on: They took something like 6 vials' worth. I don't understand your point though; could you rephrase or elaborate?
posted by saizai at 4:36 PM on April 4, 2011


Yes, it's legal. This is a kind of silly thing to be arguing with the hospital or insurance company about. All kinds of tests we laypeople know nothing about are done in the course of emergency room evaluation, diagnosis, and treatment. Obviously if you're presenting yourself at the ER with an emergency condition they need to know what drugs you may be taking that could affect your mental state, have some bearing on your condition, or interact with drugs they may give you. It kinda seems like drug testing is some kind of bugaboo that has you all up in arms ... If it was other, more esoteric blood work you didn't recognize, would you be raising Cain about that, too? Doctors get us to consent to treatment, not every little test they do in the course of that treatment. Let it go.
posted by jayder at 4:37 PM on April 4, 2011 [7 favorites]


...drug screening without my consent because they think that I would lie to them...

Or because you were being deliberately or accidentally poisoned. Maybe someone's flatmate accidentally left what was apparently a bottle of generic painkillers when they moved out and hey, painkillers, maybe now I can sleep, oh hell my cold just got worse, I'm hallucinating, wtf?
posted by Lebannen at 4:45 PM on April 4, 2011 [9 favorites]


Left an answer to another related question here about this. I’m doing a social work internship in an ER in a major hospital in Los Angeles now. I see a huge number of patient records and the drug tox is a standard test that is run on everyone. Everyone gets a CBC and a metabolic panel and all the women get a pregnancy test. There is basic information the doctors need to know to be able to treat their patients and if the patient has drugs in their system is one of them. It is assumed that when you consented for treatment, you consented to letting the doctors run any relevant tests. Those are tests that the doctors find relevant, even if the patient does not. In the ER I’m in there is no way the doctors would have time to go over every single test that is run on every patient and doing a separate consent for each one would be a huge burden on the system. That’s why they do the generic consent, so by signing that you did give them your permission.
posted by Palmcorder Yajna at 5:09 PM on April 4, 2011 [7 favorites]


Yes, it's legal. This is a kind of silly thing to be arguing with the hospital or insurance company about. All kinds of tests we laypeople know nothing about are done in the course of emergency room evaluation, diagnosis, and treatment. Obviously if you're presenting yourself at the ER with an emergency condition they need to know what drugs you may be taking that could affect your mental state, have some bearing on your condition, or interact with drugs they may give you. It kinda seems like drug testing is some kind of bugaboo that has you all up in arms ... If it was other, more esoteric blood work you didn't recognize, would you be raising Cain about that, too? Doctors get us to consent to treatment, not every little test they do in the course of that treatment. Let it go.

On one level, yes this is a silly thing to argue about, but I don't think it's really that unreasonable to be upset about it and to think this, to a layperson, isn't really something you agreed to. Certainly many patients would be furious if a doctor ran a Huntington's Disease DNA test, a paternity test, or even an HIV test without consent. Where do you draw the line and why are drug tests always on the acceptable side of it? If you're conscious and competent, doctors can't randomly perform a spinal tap on you without additional consent, even though it's just a lab test and you signed a generic consent form. It's really not such an unreasonable question to be asking, especially as it is done so routinely in many US emergency departments.

Given this nation's hang up with illegal drugs, being tested for drugs without your consent is kind of a freaky thing to have happen, and it certainly does raise some ethical concerns.
posted by zachlipton at 5:28 PM on April 4, 2011 [8 favorites]


Many hospitals have a patient advocate. Call the hospital, try to find that person, and write a thoughtful letter. I'd ask to have the charges removed, and ask for an apology. You say you were woozy, and you're a grad student, so it's not unreasonable that they would test to see if you were having an adverse reaction to drugs. But they could easily have asked you. This would bug me, too.
posted by theora55 at 5:44 PM on April 4, 2011


Everyone gets a CBC and a metabolic panel and all the women get a pregnancy test.

If I've had a hysterectomy, do I have to pay for this pregnancy test?
posted by bentley at 6:07 PM on April 4, 2011 [3 favorites]


Where do you draw the line and why are drug tests always on the acceptable side of it?

Having drugs in your system is not the same as a paternity test, or any of the other examples you gave. If you have drugs in your system they could potentially interfere with treatment. Or treatment given to you could quickly turn from beneficial to harmful because of drug interactions. It's very important to rule out foreign substances and to make sure you know what's in that patient's system before you introduce other substances to it, or perform invasive procedures.
posted by DrGirlfriend at 6:15 PM on April 4, 2011 [2 favorites]


OP: if you feel that this is not something you should have to pay for because it doesn't fall under the "medically necessary" umbrella (which I strongly disagree with, but it's the premise here), your first stop should be calling the hospital's billing office. I work in one, and my feeling is that they will not agree with your assessment and won't be removing the charge - So, your next step should be to contact the hospital's Patient Advocate office and state your case. If they agree to intercede, they'll contact the billing office and try to work something out.
posted by DrGirlfriend at 6:27 PM on April 4, 2011


Having drugs in your system is not the same as a paternity test, or any of the other examples you gave. If you have drugs in your system they could potentially interfere with treatment. Or treatment given to you could quickly turn from beneficial to harmful because of drug interactions. It's very important to rule out foreign substances and to make sure you know what's in that patient's system before you introduce other substances to it, or perform invasive procedures.

Certainly knowing the results of a drug test is important in some cases. That's why I said it "raises some ethical concerns" and didn't say it was a downright unacceptable practice. It's a hard problem without good answers, but it's not a trivial matter either. My point isn't that anyone explicitly did anything wrong here, but rather that it's not unreasonable for the OP to feel squicked out about it, as some posters implied. Certainly a paternity test (in the case of establishing a family history anyway), Huntington's Disease Trait, and an HIV test would be an important part of diagnosing some patients just as a drug screen is an important part of diagnosing some patients, but doctors don't do those tests without explicit consent and we have strict laws about who can perform them and what the results can be used for.

Think about it this way. Imagine that the OP walked into his GP's office and presented with exactly the same symptoms. Same likely goes for many urgent care centers. What would happen? Would the GP order any blood tests? Quite possibly not, at least on the first visit, though it's entirely possible, depending on the symptoms and history. Would the GP order a drug screen? I bet it's highly unlikely, absent some cause to believe drugs were involved. Would the GP order a drug screen without telling the patient? I doubt it. So it's the same patient, same case, same everything, but the drug test is medically necessary in the ED and not in the internist's office?
posted by zachlipton at 6:37 PM on April 4, 2011


If I've had a hysterectomy, do I have to pay for this pregnancy test?

Yes. After all, there could be an ectopic pregnancy or other type of non-uterine pregnancy going on, in which scenario a positive pregnancy tests results might supercede other clinical findings such as a empty/absent uterus or be the easiest/quickest way to assess for cancers affecting certain organs
posted by beaning at 6:43 PM on April 4, 2011 [1 favorite]


So it's the same patient, same case, same everything, but the drug test is medically necessary in the ED and not in the internist's office?

Yes, given the supposition that presenting to an ER means a certain amount of urgency/lack of longterm medical care. A particular pt's GP is likely to have more personal data already on file than a ER does and much more likely to be seen back for follow up care/further testing.

The OP doesn't even reference contacting a GP at all after several weeks of symptoms. As others have noted, OP presented to an ER with concerns relevant to poisoning/overdoses as well as several other scenarios. Given the urgent nature inherent in an ER visit for this concern, testing for all these is not unreasonable. If OP feels there was time to "pick and chose" testing, then OP should not have gone to the ER; OP should have found a GP when symptoms first presented.

And while the turn around time for genetic testing such as Huntington Disease does not make it a common test for ER docs, I have seen it ordered by them, particularly for centers with recurrent visits from homeless/psych pts. HIV is a very routine ER order for certain cirmstances. And there are no genetic diseases in which paternity testing is a diagnostic tool for a symptomatic pt.
posted by beaning at 7:06 PM on April 4, 2011 [4 favorites]


In the EMERGENCY context, it seems pretty clear that the staff has to figure out:
--what their options are in terms of drugs they can treat with; and
--what is going on inside of this body we're about to do stuff to.
Why WOULDN'T drugs be relevant? They want a holistic picture of what's going on. I recently went to the dentist and his questionnaire asked about drug use and drinking. I didn't go get in his face and ask "why do you wanna know?" And that wasn't an emergency. It just seems strange to be so difficult about this issue where it occurred in the emergency context ... These people, I'm pretty sure, were trying to help, and had zero interest in invading your privacy, narcing on you, or whatever. They really see it all and couldn't care less whether you use drugs, I promise. They checked only for your own good.
posted by jayder at 7:38 PM on April 4, 2011 [2 favorites]


I think the OP has left out two key details. Did they run and bill you for multiple labs (i.e lipid panel, CBC, liver enzymes etc)? If so, did they explain the rationale for each lab beforehand?
posted by space_cookie at 7:38 PM on April 4, 2011


Hal c yon- I worked in a clinical lab. Most machines take less than 50 microliters (a few drops) of plasma to run several dozen tests. In the ten years since I worked there, the amount of blood needed has gone down even more as machines have advanced. The amount of blood taken is massive overkill. There is no shortage of blood.
posted by rockindata at 7:39 PM on April 4, 2011


OP, you may find this article (it reads more like an op-ed) from Time magazine interesting:

Why ER Docs Test for Illegal Drugs Without Consent

Specifically, this excerpt poses your question but doesn't actually answer it:

"When you check in to a hospital, you sign a form giving consent for routine testing, including blood and urine tests for lots of things. This makes sense — it means that as doctors, we don't have to check with you for every run-of-the-mill test we order. But the question here is whether or not testing for drugs and alcohol without your explicit consent should be considered routine."
posted by Majorita at 8:19 PM on April 4, 2011


Yeah, there's a lot of shady shit they'll do in the hospital without getting meaningful consent. Even if you had specifically signed a consent about it - the chances that someone would sit down and elicit meaningful questions about the tests or go into the pros and cons of testing with you are miniscule. I honestly think the consent process in hospital settings is a joke. Most people have little idea why they are getting the tests or procedures they are getting, and often, as you have observed, they don't even know they're getting most of the tests or procedures they're getting.

The good news is, for the most part no one in the ER is trying to screw you over, and even if you tested positive for 10 different drugs, as long as you could walk and talk and so forth they would be unlikely to do much with the information.

Most stuff that happens in hospitals is based on protocols that are written by some kind of policy people. These protocols are designed to ensure that they save the most lives at the lowest cost. Protocols mean that everyone gets the same sets of tests (or everyone within various defined sub-groups). Sometimes these tests aren't necessary for each individual, but if they're cheap tests (for the hospital) they're worth it because they'll catch the outliers who benefit from the test.

If you are pissed about it - it can't hurt to complain. I'm a believer in the idea that making noise makes a difference, especially if a lot of people make noise.

On the other hand, no one in the ER really cares if you're high as a kite as long as you aren't in physical danger and aren't endangering others, so the unconsented test is not in reality actually causing you harm.
posted by serazin at 8:26 PM on April 4, 2011 [1 favorite]


They took something like 6 vials' worth. I don't understand your point though; could you rephrase or elaborate?

HOLY KRAP thats a lot of blood. I had a lot of blood taken from me when I was applying to live in NZ..and while I was in the USMC. NEVER have I had so much blood taken.

Sorry I was confusing. What I mean is:
When someone takes some blood from you, it is used for a test. It gets USED. They put in coagulants, chemicals, etc in those vials, run 'em in a centrifuge, etc.

When they check your blood for cholesterol(for example), they use a vial of your blood...do stuff to it, and come up with results. That vial of blood can no longer be used to test for your potassium levels.

What I was getting at was:
They used some of the vials for drug testing. Because they did that, were they able to do the rest of the tests you SHOULD have had done because of your condition. Were they able to do a CBC, cholesterol, etc?

But obviously...if they took 6 freaking vials, they were able to test for everything. Holy krap, 6 vials.

I doubt you need to do a HIPAA records release. You should just go down to the hospital, go to "records", and you should be able to get all the results by maybe paying a few dollars and signing a few forms.

Good luck, dude...and congratulations on getting out 6 vials from 1 vein!
posted by hal_c_on at 8:55 PM on April 4, 2011


But obviously...if they took 6 freaking vials, they were able to test for everything. Holy krap, 6 vials.

Is that really so much? I'm assuming we're talking about something like a standard red top or purple top vial as would be used for a CBC or a metabolic panel. I had something like 13 tubes drawn at once, including a couple of the larger culture vials, when I was 10 or thereabouts, with no real problem other than feeling a bit woozy after. Was that really so nuts?

After all, a pint is pretty standard for blood donations from healthy volunteers, at least in the US.
posted by zachlipton at 9:18 PM on April 4, 2011


Six vials doesn't seem like that much to me; I regularly have 2-3 vials drawn weekly just for the docs to keep tabs on my blood counts and a few other things as I'm going through chemo treatment, and when I get my full thyroid counts done that's another 2 vials.
posted by scody at 11:08 PM on April 4, 2011


Wow, that's a lot of comments. I'll try to answer the salient bits.

I don't remember what color tops the blood vials were. FWIW I weigh 135lb.

The other line items from that visit were (from my summary, can dig out the full version if relevant):
ER - High Severity visit
Chest X-Ray
Chem panel 1
Blood & plat ct
Blood collection

I agree that what drugs I was taking could be a salient thing for the doctors to know. What I have a strong objections to are:

a) I was perfectly conscious and they could simply have asked me - and in fact they did ask about other drugs.

b) They told me they were going to run blood tests to check if I had an infection or the like, and they also told me a summary of the results of those tests. They had the time to at the very least tell me that they were also doing a drug screen, and they presumably knew when discussing my tests that that was included. Not telling me was a deliberate act of deception, not an omission due to being too harried. That's an outright violation of my right to at the very least know what treatment I am receiving.

c) Blanket treatment agreements cannot plausibly be interpreted to mean "once you sign, they can do anything they want without telling you or having your consent". I feel that their intentional choice not to tell me about the drug screen was specifically so that I would not have the opportunity to withdraw that general consent, which is another right I do have.

I understand they don't want to do another form for every test; that's fine. This is why doctors can simply say - as they did with the other tests - "hey, we're going to run you for an xray and do blood tests for infections, ok?". It takes a few seconds, it establishes informed consent, it's simple. They failed to do so; I must presume this was intentional.

d) The ER has actual campus police - not merely security - on staff and wandering through the treatment area. If I had tested positive (I didn't), and the police happened to overhear it, that would be a violation of HIPAA but it'd also be a potential felony arrest.


I only got the results of the blood & plat ct tests when I unrelatedly went to my GP afterwards - who is in a completely separate branch of the same hospital - and he randomly handed me a printout of those tests. Since I knew he hadn't ordered any, I figured it was from the ER visit, but still, that's messed up. The ER could have given me the results.

But they have a pattern of being secretive about patients' own records. You want 'em, you have to pay and ask specially.

I'm doing a HIPAA request because I want my *full* records, and I don't want to pay them $.90/page for them like they want to charge (hardly a reasonable "copying" fee). They are able to give it to me in digital form, I want it in digital form, it's cheaper that way, and 45 CFR 164.524(c)(2)(i) requires that I get my records in the form I ask if it's reasonable. Given "print to PDF", and the fact that they have it in digital form already, it is.
posted by saizai at 11:29 PM on April 4, 2011 [1 favorite]


Oh, re GP: all my treatment is at the same hospital. (Student plan.)

My GP's office actually insisted on me going to the ER (literally they put me in a wheelchair and carted me over); I initially went to them as a followup to a visit I'd made about a few days to the severe cold/flu symptoms.

The entire hospital is on the same records system, so the ER docs did have access to my GP records, as well as my neuro etc.
posted by saizai at 11:32 PM on April 4, 2011


IANAL and TINLA, but this might be helpful information to you. There is at least one Illinois appellate case involving a patient's medical battery suit against a doctor, Moriarity v. Rockford Health Sys. (In re Estate of Allen) (2006). This case is not entirely on point, but it discusses some common law that might be relevant:

"It is well established that, at common law, a patient's consent is required before a physician may administer any kind of medical treatment to that patient. A corollary to the consent requirement is that a patient has the right to refuse medical treatment, even if the patient's life is in jeopardy."

From that same case, there is a common law "emergency exception" defense to that consent requirement:

"A medical professional is not required to obtain consent to medically treat a patient if an emergency arises and treatment is required in order to protect the patient's health, and it is impossible or impractical to obtain consent either from the patient or from someone authorized to consent for the patient.

There are four essential elements required to establish that the common-law emergency exception applies: (1) there was a medical emergency; (2) treatment was required in order to protect the patient's health; (3) it was impossible or impractical to obtain consent from either the patient or someone authorized to consent for the patient; and (4) there was no reason to believe that the patient would decline the treatment, given the opportunity to consent."
posted by Majorita at 11:38 PM on April 4, 2011


And here's a 2003 article from The American Journal of Medicine (linked to in the Time magazine article I posted above):

Should informed consent be required for laboratory testing for drugs of abuse in medical settings?
posted by Majorita at 11:41 PM on April 4, 2011


d) The ER has actual campus police - not merely security - on staff and wandering through the treatment area. If I had tested positive (I didn't), and the police happened to overhear it, that would be a violation of HIPAA but it'd also be a potential felony arrest.

I was more or less with you until you got to this point. This is really an incredibly unrealistic situation. Police shouldn't be standing close enough to overhear discussions of medical information, and if they are and you aren't under arrest, you're well within your rights to ask the medical staff to not discuss your health information in front of police officers. Beyond that issue, as discussed over in the other thread, a positive drug test isn't necessarily illegal in your state (not a lawyer, not legal advice, depends on your state and situation). A hospital drug screen isn't done for legal purposes, which means there won't be any chain of custody, backup sample, more sensitive tests to rule out some types of false positives, or any of the other protections that apply to lab tests used as evidence in court. No one could reasonably conclude you were taking illegal drugs on the basis of such a positive test alone; heck, many of the substances included in a standard tox screen are available by prescription, and no cop would know whether you had one or not.

Finally, in the phenomenally unlikely event you were arrested for a positive drug screen in the emergency room because a police officer overheard discussion of the results, I sincerely doubt charges could go anywhere, as it is my understanding this situation would likely still be covered by physician-patient privilege (again, not legal advice, your mileage may vary). See, for example, this case. You'd also probably have a cause of action against the hospital and/or physician for revealing this information without consent, and you might be able to file a complaint for breaching confidentiality against the doctor with the medical board as well.

In general, if you're not already under arrest when you come into the hospital and you don't try to assault anyone while you're there, I really can't imagine even an overzealous police officer trying to arrest you on the basis of a drug test done for medical treatment purposes.
posted by zachlipton at 12:13 AM on April 5, 2011


Having drugs in your system is not the same as a paternity test, or any of the other examples you gave.

That's actually quite true. If I do drugs, I can be convicted of a felony, lose my job, evicted form my apartment, become ineligible for many government benefits, denied custody or visitation of kids, and denied future employment, regardless of frequency, severity, and any degree of impairment, if any. By federal and state law, none of those things can happen if I am found to be a father, have Huntington's Disease, or have HIV, absent extremely good cause (i.e. I literally cannot do the job even with reasonable accommodations by the employer), and there are usually special protections against disclosing HIV status.

There are important medical reasons why doctors need to know whether some patients have taken certain drugs, and I don't think anyone has a really good sense how to deal with the issue from the medical, ethical, and legal contexts. My point isn't that the ER did something so terrible, but rather that there are very real consequences to drug tests that aren't the case for even other incredibly private forms of medical information, and we should be at least slightly concerned with the consequences of running them without consent, especially on a routine basis. Or at least we should understand why some people might feel uncomfortable about it.

If nothing else, the OP is upset about being billed nearly $80 for a test that was done without his knowledge to confirm that he's not a liar.
posted by zachlipton at 12:39 AM on April 5, 2011


I was going to write out a line by line thrashing of your reasoning, but chose not to. It boils down pretty quickly: You described yourself as feeling woozy and not correcting after a few weeks. There is enough reason to run a drug screen. It's not an implication that you are intentionally taking any illegal substances, but it is possible that you are being drugged.

From your OP: One research paper that specifically describes "psych-ward ERs" has virtually no bearing on your issue. I'm quite sure I can find a research paper that states Phrenology is real.

As for your most recent comment:
a) If you were drugged by someone else, how would you know?
b) If you did illegal drugs, and you were told there would be a drug screen, would you consent? I can't speak to the hospital's ethics rules, because some do things differently than others.
c) Maybe. They might have omitted telling you that they would run a drug screen. Or maybe it wasn't part of the initial orders and the doctor added the order on later after the blood was drawn. Never attribute malice to that which can be attributed to ignorance.
d) It's not only a violation of HIPAA, but also a breach of doctor-patient privilege, which means it would be inadmissible in court.

By the way, how much do you think you will actually get back on this? If the hospital drops the drug screen off of the bill, most of the refund goes to your insurance, not you. You will stand to save a few dollars, max. Worrying about this at all had better be for the principle and be prepared to make a big stink, else you will just waste your time. Your best bet is to speak with the Patient Advocate. Pretty much every hospital has to have one per JCAHO rules.
posted by Mister Fabulous at 1:07 AM on April 5, 2011 [1 favorite]


This seems like a strange thing to be concerned about. I mean, I understand it a little bit, but being this concerned about it basically requires you to 1) second-guess the emergency care being provided during a "High Severity" emergency visit, and 2) have the luxury of having been treated successfully enough (presumably not for intoxication that you knew nothing about) to be focused on this now. Not only do patients in medical settings lie to their doctors all the time about drug use, one can easily imagine a situation in which the hospital gets sued by next-of-kin for taking a users word for it that they were not using.

There are some tests that you have to explicitly consent for, and others that you do not. This almost certainly varies according to state law. Further, even among tests for which you have to give explicit consent, there are opt-in and opt-out versions of consent. This very much varies by state law. Changing opt-in consent for HIV testing ("Yes, I would like to get and HIV test.") to opt-out consent ("I'm going to test you for HIV unless you tell me not to.") is a major public health initiative in public health, and should be something we all support. There are certainly times that testing for drugs is mandated by state law and used punitively. (I believe South Carolina may be the state I'm thinking of that tests mother's after they've given birth and then takes away their kids based on the results.) Regardless, the hospital almost certainly knows the applicable laws and regulations, and acted in accordance with them.
posted by OmieWise at 5:44 AM on April 5, 2011


FWIW, a cop (again: actual cop, not security) walked by my "room" (read: area with screen) while the nurse was asking me questions about previous pot use, current pot use, and where I acquire it. So that's a completely realistic point. (I'm previously from CA, now in IL; in CA had legal ability to use pot for my tic disorder ["chronic muscle spasms" is explicitly in the law]; I told her I have no comment on anything outside of CA.)

Sure, I could've been drugged by someone else or accidentally. That is a vaguely plausible defense for medical necessity… vaguely. It is in no way whatsoever a defense against my needing to be informed and to consent. It was completely possible to do both, and they didn't.

That's what I'm most pissed about, not the $80 I had to pay for it.
posted by saizai at 7:00 AM on April 5, 2011


I understand your point and I am not trying to diminish the fact that you feel your privacy was violated. I am just pointing out that you signed a consent form and then gave them your blood, and if you read the consent form it is highly likely it covers them to do exactly what they did do.
posted by DarlingBri at 7:20 AM on April 5, 2011


I think that consent and giving blood has to be interpreted in the context of what was orally discussed, especially given that contract law says unilateral generic form contracts must be maximally interpreted in favor of the person who didn't draft it.

Consent is a process, blah blah, if I tried to pull this shit with an IRB I'd get slammed.
posted by saizai at 8:09 AM on April 5, 2011


do you think they are just doing that because it never happens that someone lies about drug use? Everyone does. Pretty much all positive drug tests are from people who said that they aren't using drugs. It's a pretty natural thing to lie about.

In the ED people are trying to figure out what your problem is as soon as possible and a) fix it and send you home and get you out of the way b) admit you if you have something serious going on so that you don't die.

It's extremely normal to take 6 tubes of blood. Because it is pretty time consuming to stick someone. And, oftentimes quite difficult, depending on how the patient's veins are. So...if you get a good vein, you want to get all the blood you can get. The tubes go up to the lab, and then the MD orders what they want. It's not like when you are admitted to the hospital, then the doctor tells the lab what to draw and the lab just draws those tubes.

Totally ordinary.

I appreciate your concern. But I think you need to realize that EVERYONE who does drugs lies about it. So...while you are not lying because you are telling the truth, you have the same response as someone who is lying. And since being on drugs can dramatically alter your treatment, depending on the symptoms you present with, being tested for drugs could have possibly been the only responsible thing that the MD might do in your situation.

I think you think that the MD is in the background saying "oh that person is shifty, let's test them for drugs". Where it's more like, "ok do a CBC, a UA, CMP, and...I don't know, a tox screen, just in case".

Think about it this way: anyone who was doing drugs, and lied about it, would never, ever consent to having a tox screen. So...it would be totally useless to ever ask anyone. However, there are a lot of tests you don't really consent to. Should the nurse come over and say "do you consent to having a complete blood count? your blood pressure tested? etc. etc." It's the way that medicine works, you drag a big net and see what comes up.

I guess I would say...don't go to the ER in the future, if you don't want to be tested for what they think you should be tested for. In all seriousness.
posted by sully75 at 8:45 AM on April 5, 2011


Consent is a process, blah blah, if I tried to pull this shit with an IRB I'd get slammed.

Ha! It's not an IRB. It's people trying to (worst case scenario) make sure you are not going to die.
posted by sully75 at 8:46 AM on April 5, 2011


sully75: Again, doesn't alleviate the requirement for
a) me to be informed, and
b) me to consent

I've already admitted it's potentially relevant, and I haven't said anything to imply that I thought it was malicious. I think it probably is totally normal practice.

I also think it violates basic ethical standards of medical practice and I object to it having been done at all and to having to pay for it.
posted by saizai at 9:42 AM on April 5, 2011


Your fears about the ER cop finding out you tested positive and arresting you (a fear that, honestly, really shows you know nothing about how this stuff works) really demonstrates exactly why they HAVE to test people for drugs. The same unfounded fear is what motivates people to lie when asked about drug use.

If ER cops arrested people who admit to or test positive for drug use, in the course of treatment, it would cause a groundswell of outrage in the medical community. It would prevent effective treatment of ER patients. It doesn't happen.
posted by jayder at 9:43 AM on April 5, 2011


This is why the free market approach sucks for medicine. Most of the time you don't even know what you're buying, when you do know you don't have any meaningful way to compare prices, and that isn't even getting in to situations where you are incapacitated.

People worried about medical costs, take note: over a thousand dollars was billed for something completely unnecessary here. And according to nearly everyone int eh thread, it's so normal that they find it silly to even discuss it.
posted by Nothing at 9:46 AM on April 5, 2011


This isn't House M.D., the original poster went in for flu-like symptoms. It might by CYA against lawsuits, it might be a way to recoup costs of uninsured ER visits, it might be normal, but it certainly isn't necessary.
posted by Nothing at 9:49 AM on April 5, 2011


Since it's a test and not a procedure (and you consented to the procedure part, which was the blood draw) you can't really play the informed consent card.

And since you told the nurse you use drugs, but were cagey about your current habits outside of CA,
I really don't understand why you expected anything else.

You got your medical care, you weren't arrested, now you know that in order to not get a tox screen when you have multiple vials of blood drawn, you have to be pretty specific. Refusing a tox screen is going to get you a lot of extra attention that you probably don't want, though.
posted by charmcityblues at 9:54 AM on April 5, 2011 [2 favorites]


charmcityblues: Could you explain why you think that once I agree to having blood drawn (in order to test for infections), I have somehow waived my rights to informed consent about how that blood will get used in any other way?
posted by saizai at 10:46 AM on April 5, 2011


The results of that test were medically relevant, and running it was important. When you go to the ER, you're placing your care in the hands of the doctors there, and asking them to figure out how best to help you. To do that, they need to run a tox screen. If you don't trust the ER doctors to treat you, then don't go to the ER.
posted by KathrynT at 10:59 AM on April 5, 2011 [2 favorites]


This isn't House M.D., the original poster went in for flu-like symptoms. It might by CYA against lawsuits, it might be a way to recoup costs of uninsured ER visits, it might be normal, but it certainly isn't necessary.

What do you base that judgment on? Are an emergency medicine physician?
posted by KathrynT at 11:03 AM on April 5, 2011 [1 favorite]


When they started the IV and took the blood, did you specifically ask them what they were going to do with it? If you did, did you then say that you withdrew consent for any other test? If not, by consenting the blood draw, you gave implied consent for standard labs. In the ER, a tox screen is a standard lab.

Look at the consent that you signed, if you have it. Chances are, it's very, very broad. Also, did your *total* bill come to $1050, with a copay of $78.75? Or is that just the blood work?
posted by charmcityblues at 11:09 AM on April 5, 2011 [2 favorites]


The amounts I quoted were only for the tox screen.
posted by saizai at 11:31 AM on April 5, 2011


In fairness, $1,050 is a completely made up number. No one actually pays that amount. As with basically everything in a hospital bill, the entry on your bill lists $SOME_HUGE_NUMBER along with the procedure code that tells the insurance company what each line item was for. The insurance company has a maximum amount they'll pay for a particular service, based on their agreement with the hospital/provider/network and/or their judgement of what constitutes reasonable and customary charges for that service. That amount is often a fairly small fraction of the huge number (often less than 40% I'd say), especially for lab tests. The insurance company will pay, say, 80% (or whatever the figure is based on your plan) of the allowed amount, and you'll be billed for the remaining 20%. Even if you walk in uninsured, the hospital will generally give you a decent discount as an uninsured patient and may further write off a portion of the total bill based on your income. Many hospitals offer cash or prompt payment discounts too.

In other words, the test didn't cost $1,050 and basically no one has ever paid $1,050 for it. It's just an accounting fiction.

None of this has to do with informed consent though, which is the real question here.
posted by zachlipton at 12:42 PM on April 5, 2011 [1 favorite]


I haven't said anything to imply that I thought it was malicious.

Yeah you did: "They deliberately chose not to tell or ask me about this screening." and "Not telling me was a deliberate act of deception, not an omission due to being too harried. That's an outright violation of my right to at the very least know what treatment I am receiving." and "I feel that their intentional choice not to tell me about the drug screen was specifically so that I would not have the opportunity to withdraw that general consent, which is another right I do have." and "It takes a few seconds, it establishes informed consent, it's simple. They failed to do so; I must presume this was intentional."

By all means complain to the patient advocate at your hospital about this. That's the only way this policy will be reconsidered, and it probably should be reconsidered or at least explained better. But keep in mind that strong accusatory language like you've used here will get you written off as kind of a nut, because there is no way they were deliberately trying to do something without your consent. This is a standard test done on all patients in this setting and they didn't treat you differently than they treat anyone else, and I guarantee the emergency room staff don't think this is a big deal. So tone it down if you want to be taken seriously because I think you're coming across as more crazy and upset than you actually are. Moderate, well thought out explanations of why you're disappointed and what you would like to see happen in the future will always be taken more seriously and have a higher chance of causing real change.

You also need to give up the idea that it wasn't medically necessary, there's simply no way you're going to win that one. Adding it to your complaint is going to hurt your overall argument (because it's pretty clearly wrong) so just avoid it altogether.
posted by shelleycat at 5:21 PM on April 5, 2011 [2 favorites]


The results of that test were medically relevant, and running it was important. When you go to the ER, you're placing your care in the hands of the doctors there, and asking them to figure out how best to help you. To do that, they need to run a tox screen. If you don't trust the ER doctors to treat you, then don't go to the ER.

Wellll... I don't think that's actually true. They run these tests routinely. They don't have time to decide if every single patient really needs a CBC, or a tox screen, or whatever else. This is their protocol, they do it for everyone (or at least everyone with a given set of symptoms), and they're not really doing a lot of critical analysis for a standard blood test like this, because, why bother? As many people have stated, the ER staff don't actually have much invested in whether or not this individual is high unless it turns out he's on heroin and then goes comatose so they know to give narcan (one example). This is just standard practice for this particular ER, not some doctor going through a decision tree for this particular patient, so in all likelyhood the test was not medically necessary per se. (Not to say it was harmful or even unusual).

For what it's worth, patients have a right to decline any procedure or test at any time. This is enshrined in law. Doctors are not automatically right, and an informed patient who asks questions and participates meaningfully in his or her treatment is going to get better care. I've heard (and read) plenty of doctors say this. There's nothing wrong with a patient wanting to know what tests he's submitting to, and there's nothing wrong with declining tests he doesn't want. In a better system he could have a meaningful conversation with a nurse who would explain why the test might be of use!

Checking into the ER does not take away your right to question, participate, or have control of your body or privacy.
posted by serazin at 8:19 PM on April 5, 2011 [1 favorite]


They need to know what drugs are in your system because different drugs might affect the body in a way that changes the likely interpretation of other tests. You might win the "should have been told what was going to be tested" battle but I sincerely doubt you'll win the "tests were unnecessary" battle. They very clearly are, especially in an ER context.
posted by R343L at 10:14 PM on April 5, 2011


Re. the money, here's the data from my spreasheet:

Item Billed Due from me
ER - High Severity visit $3,042.00 $318.15
ER - Chest X-Ray $361.00 $27.07
ER - Chem panel 1 $229.00 $17.17
ER - Blood & plat ct $211.00 $15.82
ER - Blood collection $35.00 $2.62
ER - Amphetamines screen $150.00 $11.25
ER - Cocaine screen $150.00 $11.25
ER - Barbituates screen $150.00 $11.25
ER - Benzodiazepines screen $150.00 $11.25
ER - Phencyclidines screen $150.00 $11.25
ER - Opiates screen $150.00 $11.25
ER - Ethanol screen $150.00 $11.25
HMO discount -$1,232.00
Insurance payment -$3,236.42

Only the ER visit itself had a service copay ($100); the rest is amount "billed" and amount I actually ended up owing. Note the giant discount, of course.

I think that that itself is pretty fishy, FWIW - the fact that they don't give you a sheet saying what things are going to cost upfront, let alone the overinflated made-up rates they hypothetically charge (to whom? I have no idea). This seems just plain shady as an accounting practice. The fact that they can charge me whatever they want (doctors don't even *know* what stuff costs if you ask them), for procedures I'm not told about and don't want, seems to me to violate basic tenets of contract law.


shelleycat: I said it was deliberate, not malicious. I don't think their motivation was e.g. to try to get dirt on me or the like; it was either routinized to the point of a non-decision, CYA, or interest in possible drug interactions. One can act deliberately in ways that merely demonstrate you don't actually give a fuck about patients' informed consent, even if you do care about ensuring their physical health.

Like I said, I frame this primarily as an ethical issue, not a medical one.

If you're right (and I think you probably are) that they do this routinely, that makes the ethical problem *worse*, not *better*. Abuse patients' rights to informed consent in a routine and even manner does not mean that it's suddenly okay.

I spoke to the "patient relations" people. Turns out their only job is to compile statistics and forward things. They sent it on to the ER head and the "patient safety" department for review. Both of which, of course, have complete conflict of interest and cannot validly review themselves for breach of medical ethics.

No doubt they'll return saying "nope, this was routine, ergo fuck off", in which case I'd have to escalate to the state level.
posted by saizai at 6:04 PM on April 6, 2011


I think that that itself is pretty fishy, FWIW - the fact that they don't give you a sheet saying what things are going to cost upfront, let alone the overinflated made-up rates they hypothetically charge (to whom? I have no idea). This seems just plain shady as an accounting practice. The fact that they can charge me whatever they want (doctors don't even *know* what stuff costs if you ask them), for procedures I'm not told about and don't want, seems to me to violate basic tenets of contract law.

Yes. Medical care is fucked up in this country. Welcome to 2011. Unfortunately, this is how every single hospital bill works (I suppose with the exception of military and VA hospitals to some extent), and you aren't going to change that practice without completely reforming major parts of the health care system in America. No one, including staff at the hospital nor the state regulator, will take you seriously if you argue that you don't have to pay a hospital bill or portions thereof because you didn't get a price list and sign off on each line item in advance.

You're not outright wrong certainly and you make some reasonable points, but the entire industry isn't going to change the way it operates because you complained.
posted by zachlipton at 7:30 PM on April 6, 2011


Right, so you're not saying they're 'malicious' just that they don't give a fuck about informed consent and deliberately keep their patients in the dark so they can run whatever tests the like. Except that that sounds like the same thing to me. There is no way they hold the views you think they do, no one is trying to hide things from you, and no one was deliberately trying to withhold informed consent. Seriously, you're sounding like a total crank and this kind of language and tone will get you totally written off as one by the hospital.

And I'm not saying this is routine, Palmcorder Yajna who works in an ER says this is routine.
posted by shelleycat at 8:13 PM on April 6, 2011


People are talking past each other a bit here.

The ER staff were, in all likelihood, doing the very best job they could and were in no way trying to trick or misinform the OP.

The tests are routine. They had sufficient consent to do them. And they did not do them with malicious intent.

But the current system for medical care is practically designed to leave patients feeling like the OP does here. The billing battleground between hospitals and insurance companies that leaves people saying things like "the bill is an accounting fiction that no one ever pays," the lack of primary care which leaves emergency departments overtaxed, and the constant rhetoric that medical care is something a person can purchase like a pair of shoes, results in a very fucked up system. And while no individual actor involved in this encounter was acting with malicious intent, that doesn't mean the outcome is right. That's what people saying "not okay" are reacting to.

In short: No one was trying to screw you. But you are getting screwed. We all are. And there is nothing you can do about it.
posted by Nothing at 4:41 PM on April 13, 2011 [1 favorite]


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