Cost-awareness anecdote: Blood Test Surprise (contest finalist)

The following anecdote is from Brad Wright, a graduate student from Durham, NC

In the spring of 2005, the sinus infection returned. I awoke severely congested with a pounding forehead and pain around my eyes that grew worse when I bent to tie my shoes. The feeling was familiar. Two years earlier, I had similar symptoms, but was uninsured and endured a miserable week with nothing but over-the-counter medication. Now they were back.

Fortunately, when I started graduate school, my father insisted that I have health insurance. As a healthy 24 year old, I didn’t see the need, but he agreed to foot the bill for a high-deductible insurance policy to cover me in the event of catastrophic illness. Except for four physician office visits subject only to a $35 co-payment, my policy offered no benefits until I spent $3,000 out of my own pocket. With my sinuses throbbing, I knew I needed to use one of those visits. Overwhelmed by the list of “in-network” providers on the insurer’s website, I picked an internist based on convenience—his practice was located in a medical complex near my home.

Arriving for my appointment, I checked in and presented my insurance card to the receptionist. “Your visit today will be $35,” said the woman behind the desk. I was relieved to hear that my coverage was working as promised. A nurse ushered me to an exam room, where the physician promptly entered, half-heartedly listened to my complaint, and confidently asserted that I did not have a sinus infection because I had no fever. I wanted to say “Really? Mind handing me a tissue so that I can show you what’s been coming out of my head?” but resisted the urge. Instead, I clarified that fever or no, I didn’t feel well, and believed my sinuses were the culprit. At this, the internist lost patience. He ordered some lab work and a sinus CT scan to rule out infection, and said that I could have everything done downstairs.

Despite my $35 office visit, I knew my insurance wouldn’t cover anything else until I met my deductible, so I needed to find out the cost of the CT scan. Doing so was much more difficult than I expected. Admissions didn’t know the cost, so they called the imaging department. Imaging had no idea, and threw it back to admissions where, after much searching, a big black binder full of prices was located in a cabinet, alongside packets of coffee creamer, some paper clips, and a couple of dried up ink pens. The sinus CT would cost roughly $900, which I could not afford. I headed instead to the lab to get my blood drawn, not knowing that I was about to make a costly mistake.

I worked as a phlebotomist during college, so I knew that lab tests were expensive, but that most insurers negotiated discounted rates that were only a fraction of the sticker price. Besides, the lab work was routine—a comprehensive metabolic panel and complete blood count—so I didn’t think to ask how much it would cost. My mistake was assuming that the lab was in-network, because the in-network internist I had just seen worked in the same building and referred me to the lab.

A month later, the bad news came in the mail. The lab was out-of-network, and I owed $478. While this wasn’t the five-figure medical bill many families face, everything is relative. For me, a graduate student living almost entirely on borrowed money, the bill changed how I bought groceries, socialized with friends, and commuted to school. For six months, I fought to scrape together enough money to make monthly payments. The experience, while costly, taught me a lot about our fragmented health care system, how little patients or providers know about the real cost of health care, and how hard it is for patients to make price-based decisions when the system isn’t designed with that in mind.

I had learned my lesson. Later, when a dermatologist put me on medication requiring monthly blood tests, I took out the yellow pages, looked up laboratories, and dialed the phone. “I’m uninsured,” I said (not far from the truth given my coverage) “and I need to have a lipid panel and a liver function test. How much will this cost?” Some labs knew, and some labs didn’t, and the answers varied widely. Needless to say, I chose the least expensive option. Making the decision was easy, getting the information on which to base the decision was—and is—the real challenge.