Thursday, December 2, 2010

Cost-awareness anecdote: Three Ultrasounds (contest finalist)


The following story is from Tarcia Edmunds-Jehu, a nurse-midwife from Boston, MA


Sitting in an exam room I am watching my patient struggling to ask a difficult question that she clearly does not want to ask. After several attempts at starting and a few half finished sentences she finally manages to mumble a request for help with obtaining food for herself and her two daughters. She is a 41-year-old woman, 32 weeks pregnant with her third child, and working a full time job as a CNA in a local nursing home. Her husband is also working full time as a janitor. At her initial visit she denied any issues obtaining food for herself and her family, and declined any referral to social services.

“Has the work situation changed for you or your husband?” No. “Have you always had difficulty getting food and did not want to ask?” No. “Is there some reason you need more food than you needed before?” No.

“Is there some new expense that is taking money that you used to be spending on food?”
Tears begin to flow and she starts to talk. She tells me that she had been in this country for 5 years and never had public assistance of any kind. She talks about her long hours working 2 and sometimes 3 jobs in order to have enough money to keep her family afloat. She talks about putting herself through school to become a CNA while still working to pay her bills. Until last year she was doing this alone, making not only money to provide for her family, but also the money needed to bring her husband here. She had never asked for help or let her children go without. But now she is unable to pay her bills and buy food. What is the tipping point for her ability to provide for her family?

Three ultrasound bills from this pregnancy.

She is 41 and had opted for an early screening test at 12 weeks that combines ultrasound and blood tests to give an estimated risk for Down Syndrome. She made this decision after a visit with a genetic counselor and had the test despite the fact that the results would have no effect on the outcome of her pregnancy.

At 18 weeks she had a fetal survey ultrasound that patients have routinely to check the anatomy of the baby and rule out anomalies.

At 30 weeks she had an ultrasound to check the growth of her baby because she was over age 40. This is following hospital protocol; despite the fact that there was no clinical indication her baby was anything but well grown.

This patient had private insurance through her job. Very few of my patients have private insurance, and at that time I worried less about a patient with a full time job who had private insurance meeting her needs than I did about a patient on welfare with state insurance. It didn't occur to me to ask a patient if her medical bills were paid in full, or if she was responsible for paying a percentage or had a deductible.

The patient had insurance that would pay 80% of procedures, including ultrasound. Her insurance had deemed her 18-week fetal survey as necessary and were paying 80%, the other 2 ultrasounds were not considered necessary. She had a bill for close to $1400 that she had been paying off weekly for three months.

It could just have easily ended up that I would never have known about these bills, and in fact that may have been the case in the past with other patients.

We almost never think about what a test costs or whether it is paid for. Trying to find out the cost of a test is sometimes almost impossible. We almost never stop to think if a test is really indicated, or if the results will change the course of their treatment.

As providers we order tests because they are there, or because it’s easy, or because everyone gets them, or because we are scared if we don’t we’ll be sued, or because of arbitrary protocols. Sometimes we order tests because it’s the best thing for a patient.

No one orders tests thinking we might be taking food out of the mouths of our patients and their families, but sometimes that is exactly what we are doing.

10 comments:

  1. It is somewhat bizarre to read this account of a physician observing his patient's financial distress as if he was an observer on Mars and had not role in ordering the tests and setting prices for them.
    A quick check of prices for prenatal ultrasounds shows a range of $150 to $200. I don't know why this patient has a bill for $1400 for two prenatal ultrasounds but one would think that this is something that the doctor should have some control over.
    This story does highlight the complete cluelessness of doctors about the cost of medical care and the fact that they are oblivious to any role they may have in setting fees and controlling costs.

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  2. This is an issue I have not heard discussed. My family also has private insurance and we live off of one income so I can raise and school our four children. After complications from a pregnancy loss and an emergency d & C from complications from the miscarriage, We are inundated with bills. Our insurance covers 90% after deductible and co-pays. Every ER visit I was left with $300 bill and I was in ER 3 times beofre I lost my baby. Then there is the emergency I had in the hospital. Pathology was @$254 to examine the tissue, anethsthia was $1100 for the spinal, each bag of blood I beleive will be @ $500 but, I havent recived that bill yet. From this pregnancy we have more than we can afford and we are on no government assistance nor care to be. There are average hard working people like us who are just overwhelmed by medical bills and have to make difficult heart breaking choices like not having enough food, not having a vehicle, place to live, children going without, I am sure the list is endless.Had my baby survived and we went on to have our homebirth, it would have been cheaper to pay out of pocket then have insurance cover it.

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  3. I have problems with this essay:

    1) Regarding the first trimester ultrasound - It's reasonable for patients to elect for Down syndrome screening even if they decline amniocentesis or the results wouldn't change their thoughts about the pregnancy. For some patients knowing that they are lower risk based on the screening gives them piece of mind. The patient saw a genetic counselor, so you'd assume she got the appropriate counseling regarding the test and chose to do it.

    2) Regarding the 3rd trimester growth ultrasound- It's reasonable to perform an ultrasound for women >40. The author states: "There was no clinical indication her baby was anything but well grown." Checking fundal heights is a so-so screening test for poor growth. In an at-risk population, performing a 3rd trimester growth US is reasonable.

    3) The numbers don't add up. $1400 for two ultrasounds and 20% of a third doesn't make sense.

    Should this woman be saddled with these big bills? No. Insurance should pick up the NT scan and the growth scan. If they won't (despite both being standard practice), then the hospital should comp the procedures or give her a major discount. That said, neither of these procedures are "unnecessary."

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  4. I think the other posters neglected to note that the insurance deemed the other ultrasounds unnecessary and refused to pay ANYTHING on them. This patient should not have been billed for these ultrasounds by her health care provider unless she was informed up front by the the provider that they would not be covered by insurance and signed a waiver agreeing to pay. In any case, the story illustrates the hold that insurance companies and high costs of medical care have over us. Having a husband with a chronic medical condition, I can attest to this, even though we have health insurance.

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  5. This is not meant to sound heartless, but probably will anyway. This family should not be having more children. They are living too close to the financial edge as it is. Why did they make this choice?

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  6. There was a study some time back where the electronic tablet the provider used to order tests contained the coats of the tests and the amount the patient had to contribute according to their insurance. The results were fewer tests were ordered. All actors in this system think everything is free. It's time it stops.

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  7. Information of Pregnancy Ultrasound Week-by-Week

    3D Ultrasounds

    3D Ultrasound is a step in the traditional 2D tests used in medicine today. Modern technology has made it possible to make images of fetus while still in the womb.

    Today Powerful computers Technology and software’s now can be produced wonderful images of the baby inside the uterus. Which Never before such a clear image was available.

    In a conventional 2D scanning the ultrasound image is composed of a series of slices and can be viewed one at a time. Although the picture is very instructive, the picture you see does not look like a little baby.

    With 3D Ultrasounds is a series of echoes from different angles that can be stored digitally, then the shadows to produce photographs of life as the fetus.

    The vast majority of the time, 3D Ultrasounds will introduce you to your baby and reassure you that he or she is well and healthy development. In very exceptional cases where there is a problem; 3D Ultrasounds may help you understand exactly what they can prepare in advance for any treatment needed.

    Did you have a 3D Ultrasound is actually good for your relationship with your little one Unborn Child? Well it is! Studies show that mums who have the 3D/4D Ultrasounds before birth bond better with their babies. Moms make Strong and very important connection with their little baby and feel like they "know" their baby better when he or she is born.

    4D Ultrasounds

    You may have heard of 4D Ultrasounds? What is the difference? Instead, consider one of the baby pictures, like snapshots; 4D is in four dimensions ultrasound examinations, which creates the live action images of the unborn child. There are many advantages of 4D Ultrasounds technology in pregnancy.4D ultrasounds assembles pictures into time series, in other words, You Can See the Video of the little baby inside the womb.

    Depending on how the baby is active during the inspection, you may be able to see the movement of your child's hands and feet, or even watch a yawn, blink, sob, or wiggle of the fingers. If you’ve been feeling a little anxious about the health of your baby—and what pregnant mum doesn’t?—seeing this can be extremely reassuring.

    Important Information

    Normally 4D Ultrasound is used 24 to 34 weeks. Before 24 weeks the little baby is not developed enough for it to be really beneficial. 27 to 34 weeks baby has enough fat, and there is still possible to move, so the pictures are excellent. This experience with the 3D/4D ultrasounds is amazing and I would recommend it to especially pregnant women’s. See your unborn baby up close and personal. This experience would be incredible, and unforgettable.

    Sometimes a two-dimensional ultrasound shows a problem. While 4D Ultrasounds used to confirm an anomaly. Most centers that perform a 4D Ultrasounds , recommends that the test performed after 20 weeks of gestation. It is when the child is usually large enough to see the features.

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  8. I wish someone would remove the 4D ultrasound comment, as it is obviously spam and completely inappropriate (even offensive in the context of this story).

    Re: Mark's comment - "I don't know why this patient has a bill for $1400 for two prenatal ultrasounds but one would think that this is something that the doctor should have some control over." One would think so, but one would be completely wrong. The doctor may play a role by ordering the test, but has no say in how much the test costs, or whether the insurance company will pay for it (he/she can appeal a company's decision on the patient's behalf, but that's about it). As the writer summarizes, health care providers order tests for a multitude of reasons, some better than others, but the majority of the time it's because we think it's what's right for the patient. It is heartbreaking when situations like this occur, and unfortunately it's far more common than anyone wants to admit.

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  9. I'm 9 weeks pregnant right now, and without specific billing codes, any ultrasounds beyond the one at ~18 weeks would cost $490 out of pocket each. That fee does not cover the doctor's visit co-pay or any additional testing, so that $1,400 is not all that surprising.

    I had an abdominal issue earlier this year and they did an upper GI ultrasound - insurance got invoiced $270, allows $93, and since that is under my deductible, I am responsible for that. Add in the co-pay at the Dr and some medicine, and that trip cost almost $150 and accomplished nothing.

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  10. 3-D ultrasound can furnish us with a 3 dimensional image of what we are scanning. The transducer takes a series of images, thin slices, of the subject, and the computer processes these images and presents them as a 3 dimensional image. Using computer controls, the operator can obtain views that might not be available using ordinary 2-D ultrasound scan. The scans requires special probes and software to accumulate and render the images, and the rendering time has been reduced from minutes to fractions of a seconds. M-F 10am-8pm Saturday and Sunday 10am-4pm. 4d ultrasound

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