Thursday, December 29, 2011
Monday, December 19, 2011
Patients and their caregivers are uniquely positioned to recognize inefficiency in the healthcare system but are seldom empowered with information they need to reduce harmful spending. With the help former Surgeon General C. Everett Koop, former White House Budget Director Peter Orzsag, former Michigan Governor Jennifer Granholm, women’s health advocate Dr. Susan Love, and Harvard University Provost and health economist Alan Garber, Costs of Care launched an innovative essay contest this Fall aimed at elucidating both the challenges and opportunities to save patients’ money with routine, cost-conscious medical decisions.
From Labor Day through November, Costs of Care gathered more than 100 personal stories from patients, nurses, and doctors across the nation. According to Dr. Garber, "These stories vividly illustrate some of the anomalies of our health care system - such as its use of market-like features without the all-important requirement of price transparency. The past two years have taught us how difficult it is to reach a political agreement about solutions to the problems of our health care system. But we should never lose sight of the challenges many Americans face in getting appropriate care and paying for it. The problems are all too real."
You can read more about the contest and the submissions that were selected as finalists in our official press release here: http://www.prweb.com/releases/
Saturday, November 5, 2011
This post is by Katie Vahle, co-founder of CoPatient, LLC
What if everyday purchases were priced and consumed like healthcare services?
These days you’d have to try hard not to know the price of a product or service before you buy it. So imagine booking an airline ticket with zero knowledge of the cost, only to return home to a bunch of outstanding bills for the trip. One statement may cover the seat rental and fuel used. Another bill may itemize each time the flight attendant handed out drinks. A few weeks later a bill for the pilot’s flying time may roll in. Can you imagine the resulting confusion, stress and angst?
I know it sounds absurd but this is the nightmare patients face every time they use the healthcare system. And it isn’t uncommon for these confusing medical bills to spiral out of control. Last year, the Commonwealth Fund (a non-profit healthcare research group) reported that 20% of US adults had medical debt or faced problems paying medical bills and only 58% of Americans felt confident they would be able to afford the care they needed.
So what options do consumers have when faced with the reality of paying for their healthcare?
Option #1: Prepare ahead of time. Ideally everyone would find the right insurance policy and shop for services before care is needed. The good news is price-shopping tools are coming to healthcare. Companies such as Healthcare Blue Book, Out-of-Pocket, and Fair Health allow patients to research prices ahead of time. Taking price transparency a step further, straight into the hands of doctors, Cost of Care will make it possible for physicians to consider the cost of medical care as they treat patients.
Inevitably, there are going to be situations where cost cannot be considered beforehand. What options remain for patients facing the resulting bills, explanation of benefits (EOBs) and insurance policy questions? And it’s not just those without medical insurance that face these problems. In 2009, researchers at Harvard University reported medical debt was involved in roughly 2/3 of bankruptcies, even though the majority of those individuals had health insurance!
Option #2: Deal with the aftermath. Most consumers are left to sort through the resulting pile of medical bills to understand how much is owed and if the statements are correct. Healthcare experts are regularly quoted estimating 30% to 80% all medical bills contain mistakes. But just because mistakes happen, it doesn’t mean they are easy to identify and fix.
This is the reason we launched CoPatient. We set out to create a community-based resource where patients can find answers to questions about their medical bills … where caregivers can understand if these bills contain errors … where everyone learns about options to reduce the burden of their medical debt. Rather than consumers facing their medical debt in isolation, imagine a web-based community that demystifies medical bills while pointing out potential errors or ways to negotiate down the debt.
The next time you receive a medical bill in the mail, consider taking action to make healthcare more affordable for yourself and the broader community.
Step 1: Remain Calm. Take a deep breath and don’t let the deluge of paperwork overwhelm you.
Step 2: Get Organized. Sign up for your insurance company’s website to access documentation about your benefits and keep track of EOBs. Reach out to the hospital and doctors’ offices to request copies of each itemized bill.
Step 3: Join the Community. Work with an advocate to recognize errors on your medical bills and identify ways to negotiate a lower price.
Aggregating the experience of those who are dealing with medical bills and sharing that information widely will make everyone facing medical debt better off. It will be services like CoPatient that will help patients understand and manage their medical debt, putting them on a path to physical and financial recovery!
• Schoen, et al. How Health Insurance Design Affects Access to Care and Costs, by Income, in Eleven Countries. Health Affairs Web First, Nov. 18, 2010.
• Himmelstein, et al. Medical Bankruptcy in the United States, 2007: Results of a National Study. The American Journal of Medicine. Vol 122, No 8. 2009.
• Silver-Greenburg, Jessica. How to Fight a Bogus Bill. Wall Street Journal. February 19, 2011.
Saturday, October 22, 2011
Ian Metzler is a medical student at Harvard Medical School, currently studying health systems improvement at Children's Hospital Boston
John G. Meara MD, DMD, MBA is Associate Professor in the Dept of Global Health and Social Medicine, and the Director for the Program in Global Surgery & Social Change at Children's Hospital Boston
As of June last year, Americans now owe more in student debt than they do in credit card debt. Student borrowers are winning the dangerous debt race as both amounts hurtle toward the $1 trillion marker, student debt rose by over 500% since 1999 (1). To put this in perspective, student debt has increased at nearly double the rate of inflation seen in the housing bubble that caused the recent financial crisis. There are foreboding similarities between real estate and education. Until 2008, it was assumed that both commodities would unfailingly rise in value and that the market was far from saturated. However, the number of unemployed college graduates is rising and a recent report found that two out of five student loan borrowers were delinquent on their payments at some point in the first 5 years of their loan (2). Moreover, unlike credit card or mortgage debt, student debt is not diffusible through bankruptcy, it stays with borrowers for life.
Despite this unstable situation, in August 2011 Congress passed the Budget Control Act that will abolish subsidies from a pillar of education finance—the Federal Direct Stafford loan. Although undergraduates with the loan will continue to receive subsidies, graduate students will start accruing interest while still in school. With the skyrocketing costs of higher education and the increasing time it is taking post-grads to pay off their loans, this amount adds up quickly. For example, a medical student who matriculates in 2012 and receives the unsubsidized Stafford loan for all four years of her schooling will graduate with $5000 more in debt than a medical student who graduated this year, all resulting from interest charges that accrued while she was studying full time. It often takes medical students 10 years or more to repay all their debt, and in that time interest will continue to add up so that she actually pays $10,000 just for the interest on that single, federally-provided loan. In total, $18 billion is being passed off onto graduate students over the next ten years (3) The removal of subsidies is a subtle step but it sends a strong message. If the federal government continues to retract its commitment to financially support higher education, it risks three major effects: exaggerating the student debt crisis, inhibiting diversity in higher education and discouraging the pursuit of non-profit or socially responsible careers.
Of the many students now financing their higher education, medical students take on the greatest debt because they borrow the largest amount upfront and often defer their payments during residency. With the average indebtedness now at $157,990, the extra $10,000 from the loss of subsidies may seem insignificant, however, it’s an abrupt addition to an already tenuous debt situation (4). The interest rate on the Stafford loan has more than doubled in three years, rising from 2.8 to 6.8%. Total student debt at graduation has increased by 74% since 1999, about 6-7% per year most recently. With physician salaries increasing at rates between 2.6% for primary care physicians and 4.3% for specialists, the debt-to-salary ratio gap is widening quickly and this strain is unequally imposed on endangered primary care doctors. Currently, medical graduates are required to commit approximately 9–12% of their after-tax income to paying off their educational debt (5). This leaves many physicians paying off their loans into their 40s and 50s, when they should be saving for their children’s tuitions.
Event with its precipitous rise, the threat of debt has not curbed the attraction of medical school; there are now two applicants for every one spot (6). But this should not be hailed as a sign of a healthy system. While the applicant pool may still be competitive, it is becoming more economically and ethnically homogenous (5). Over half of medical students now come from families in the top 20% of incomes while only 3% come from the bottom 20% (7). Despite fervent efforts by medical schools to build diversity in the classroom, cost remains the strongest deterrent to minority students considering a medical degree.8 Studies have shown the benefits of a diverse physician workforce, but the escalating financial commitment is discouraging those students that the profession needs the most (8).
The specter of debt profoundly influences students as they consider their post-graduate career options. Graduating medical students must pick between careers with large salary disparities. Not surprisingly, studies have shown a correlation between the higher paid specialties and the number of residency spots filled (9). As average indebtedness has dramatically risen, the number of applicants to primary care residencies has been shrinking. The annual survey of graduating medical students by the American Association of Medical Colleges (AAMC) found that 42.5% were influenced by their level of debt when choosing a specialty (3). The relatively low pay of primary care careers compared to sub-specialties and the pressure of over $150,000 of debt weighs on the minds of even the most altruistic students. This dilemma is not limited to medicine; these same pressures apply to any graduate student trying to leverage an advanced degree to aid their community. Congress’s removal of subsidies across the board will only further tip the scales away from socially responsible career choices.
Some may argue that the government’s provision of financial aid has caused the inflation of educational debt by making it too easy for students to acquire loans. While there is some evidence that increased federal funding results in educational institutions increasing tuition to match demand (10) this doesn’t mean the solution is for the federal government to join the feeding-frenzy. Even if reducing access to loans would exert pressure to lower tuition, it will disparately discourage minority students and those from families with lower socioeconomic status. Removing interest subsidies while maintaining the availability of loans will do worse by drawing students further into unsustainable debt and doing little to curb education costs. If our country wants to continue producing diverse doctors dedicated to serving their community, it should not discourage higher education by making the debt burden untenable. Instead, it should support the efforts of students with continued financial aid and work with institutions to lower tuitions and increase the value provided to students.
The Budget Control Act may not be the only legislation coming from this Congress that threatens medical education. A joint select “super” committee will be formed to propose plans for a $1.2 trillion deficit reduction. Federal loan programs are not immune to further cuts; more subsidies could be removed, even for undergraduate students, or the total amount of aid available could be reduced. Graduate medical education funding will certainly be considered since previous proposals included cuts in Medicare’s contributions to resident salaries and the academic hospitals that train them. Insecurity about funding and support during residency training will further strain the minds and wallets of young physicians, forcing them farther from lower paid primary care careers. If we want the United States to remain a leader in healthcare innovation and produce a generation of physicians capable of surmounting this century’s challenges, we must give a voice to future students and demand that our government protect those that pursue higher education and socially responsible career choices. Without continued support, the medical profession will end up crippled and distorted by the growing weight of unmanageable debt.
1. Indiviglio D. Chart of the day: student loans have grown 511% since 1999. The Atlantic. August 8, 2011. Accessed September 7, 2011.
2. Hacker A, Dreifus C. The debt crisis at American colleges. The Atlantic. August 17, 2011. Accessed September 7, 2011.
3. Nelson L. A graduate student burden. Inside Higher Ed. August 17, 2011. Accessed September 7, 2011.
4. Association of American Medical Colleges. Medical School Graduation Questionnaire: All Schools Summary Report: Final. Available at: http://www.aamc.org/data/gq/allschoolsreports
/gqfinalreport. 2009. Accessed September 7, 2011.
5. Jolly P. Medical school tuition and young physicians' indebtedness. Health Aff (Millwood). Vol 24. 2005:527-535.
6. Association of American Medical Colleges. Applicants and Matriculents Data. Available at: https://www.aamc.org/data/facts/applicantmatriculant. 2010. Accessed September 7, 2011.
7. Greyson SR, Chen C, Mullan F. A History of Medical Student Debt: Observations and Implications for the Future of Medical Education. Acad Med. Vol 86. 2011:840-845.
8. Sullivan LW. Missing Persons: Minorities in the Health Professions, A Report of the Sullivan Commission on Diversity in the Healthcare Workforce. 2004.
9. Ebell MH. Future salary and US residency fill rate revisited. JAMA. Vol 300. 2008:1131-1132.
10. Singell LD, Stone JA. For whom the Pell tolls: the response of university tuition to federal grants-in-aid. Available at: http://darkwing.uoregon.edu/~lsingell/Pell_Bennett.pdf. 2005. Accessed September 7, 2011.
Friday, September 23, 2011
Tarcia Edmunds-Jehu, a nurse midwife from Boston, MA, beautifully captured how the current health system leaves some patients struggling desperately to pay bills - and providers feeling terrible that their well-meaning care is to blame.
Ultimately, the stories came from nurses, patients, and doctors from more than thirty states - Alaska to Texas, New York to California, North Dakota to Florida. The contest was covered in the national media, including NPR and ABC TV. And a great conversation about routine opportunities to save money in the healthcare system with better decisions was started.
Stayed tuned for information about our 2011 essay contest launching soon!
Thursday, September 1, 2011
Daniela Carusi, MD, MSc is an obstetrician/ gynecologist practicing in Boston, MA
A friend of mine recently took an exotic trip. While shopping in a market, she picked up an appealing item and asked the seller what it cost. She was given a price that seemed high, and paused to consider whether the impulse seemed justified. The shopkeeper grew confused in the silence. Finally he asked my friend, “Don’t you want to know if I can do better?”
Clearly this person was outside of her bargaining comfort zone. Many – perhaps most - Americans are accustomed to paying the price as written on a tag. If you have to ask, you can’t afford it, or so I was told growing up in suburban shopping malls.
American consumers make the same assumptions as they search for transparency in health care costs. Obviously there are charges for these services – they are clearly written on the bills after the services are delivered. So why is it so hard to find out the cost of a service before it is performed? Here it is essential for the customer to understand that the charge and the price paid may be quite different; in fact, they are expected to be different. The health care consumer is not shopping in a chain store whose clerks forgot to stamp the items with their prices. On the contrary, the confused shopper has stumbled into an exotic market without a clue on how to haggle.
I work for a large health care system in a metropolitan area. I am well aware that the amount we charge for services is far higher than the amount we collect from payers. In fact, government payers will often pay 25 cents on the dollar, while private insurance companies will pay more. Still, we rarely receive more than 50 percent of what we charge. The reasoning behind the sky-high price tag always eluded me, and when I saw its effect on my self-paying patients, it infuriated me.
It is no secret that large insurers negotiate payments with health care facilities and providers. We charge a fee, the insurer hands over the pre-negotiated payment, and we do not ask the patient to make up the difference (such a system, known as balance billing, is not permitted where I practice). The patient pays his or her copayment, and the transaction is closed. The same occurs with government payers, though the negotiation seems a touch more one-sided.
This system breaks down for the uninsured patients – either those who have no coverage at all, or those seeking a particular service that is not covered by the insurance policy. The same exorbitant charge will go out to the individual consumer, who will assume (rightly so) that the entire amount is due. Failure to pay the bill lands many an American into financial straits. On a few occasions my billing service has sought permission to send a collections agency after a non-paying patient. Such a decision feels entirely counter to my doctor-patient relationship, one in which I want to support and advocate for my clients.
Once I understood this system I tried to make it feel fair. When I had an uninsured patient, I asked my billing service to charge a discounted amount, calculated by averaging my collections from all payers for that particular service. This met with great trepidation from the billing office. I was informed that it was impermissible for me to charge different amounts to different patients. No one had any problem with the fact that I was going to collect twice as much from the uninsured customer as the insured one. As the shopkeeper, I was expected to throw out the same initial number when asked to charge for my service, but no one was turning to the uninsured patients and saying, “Don’t you want to know if I can do better?”
This is why cost transparency in health care is so difficult. We can’t predict what the final negotiated payment will be without knowing who is paying and what kind of bargaining position that person is in. And no one had taught the individual consumer the rules of the game. Physicians may be criticized for not knowing the costs of the services we order, but there simply is no straightforward answer.
I look forward to the day when health care charges and collections can be both uniform and reasonable. I am thrilled that consumer advocates are seeking clarity in health care costs, but they must understand what all this encompasses. The cost must reflect not only the price of facilities, supplies, high-tech equipment, and service providers, but also the bargaining position of the person who pays.
Do we as health care consumers require a crash course on bargaining? I’ll give it a go for some sparkling jewelry, a piece of furniture, or even tonight’s dinner. But when facing a major illness I’d prefer a price tag, thank you.
Monday, August 22, 2011
Jeffrey Herman is a sophomore at Brandeis University and just completed a summer internship with Costs of Care.
I can’t think of a single industry that is more inherently personal—more emotional than health care.
Everyone has a story of how the health care system has impacted their lives. My family’s experience with the healthcare system had both positive and negative results. Thankfully, my brother survived a brain tumor as a young child and my father’s heart disease was treated early enough to prevent a heart attack. However, the bills for these procedures were astonishing. Perhaps even more shocking was the complete inability of doctors and insurance companies to give an accurate estimate of what the procedures would cost. There was no more clarity with routine follow-up procedures like MRIs and stress tests. On any given day, a doctor may order the same test several times, so how does uncertainty exist about how much it costs? And if doctors don’t know the cost, how are patients supposed to be informed consumers of health care?
Many insured patients don’t worry about how much a procedure costs—frankly, with third-party payers, they often don’t have to. In fact, if you are sick and diagnostic tests are covered, you might push for your doctor to administer all potentially beneficial services. However, at some point the over-utilization of services at unclear prices results in detrimental care that is ultimately more costly than helpful. In some cases, particularly for patients with high deductibles or loop holes in their insurance plans, these costs may even cause significant financial harm.
When policymakers and doctors try to arbitrate solutions to the problem of price transparency, progress often can seem out of reach. Most avenues to change are either politically unpalatable or financially impractical. So instead, I propose addressing the problem from a grassroots level. To fix the American health care system as a whole we must engage consumers and doctors to care about it on a personal level. Informed consumers will push for efficient stewardship of resources and doctors will oblige if there are the right incentives to do so.
Several websites, such as Clear Health Costs and HealthCare Bluebook, provide easily accessible information about the price of various procedures. Clear Health Costs even breaks down prices by specific physicians/hospitals. If it is so easy to find reasonably priced care, patients will be more inclined to be cost-effective consumers. Additionally, such websites could exert competitive pressure on caregivers to both have reasonable prices and to be knowledgeable of what their services cost. Assuming that these websites will expand and spark similar sites, they will become an invaluable resource for health care consumers and caregivers.
The widespread use of social media also has significant potential to provide cost information to consumers. Eventually, Twitter and Facebook users may be able to access price information while connecting with friends, family, and other aquaintances. This convergence of health care information with personal networks promotes knowledgeable consumers. Perhaps more importantly, if these health care cost-consciousness permeates social media, users will feel social pressure to spend resources wisely. Imagine 750 million Facebook users with a price transparency application that appears in a newsfeed right along with friends’ status updates and wall posts.
After reflecting upon the state of the American health care system, it can be difficult not to feel optimistic. Party politics seem to overshadow progressive policies. Any potentially beneficial policy or idea is immediately rejected because it will be politically inflammatory or financially taxing. However everyone—on all ends of the political spectrum—can agree that change is necessary. Perhaps a grassroots approach that engages the public in cost-effective care with greater price transparency will bring about much needed reform. Providers and lawmakers will take notice if the public pressure is great enough. Ultimately, it is up to us.
Sunday, August 7, 2011
I would like to share a story about my son’s recent surgery that, while only one simple case, reveals the foundational problem with the U.S. health care system.
I write this story as a father of a 12 year old boy who has cerebral palsy. Jack is fortunate to be healthy and active with minor medical needs. As he has grown he experienced some issues with contractures in his right lower leg which recently required a minor 2 hour outpatient surgical procedure. That is where our saga begins.
When Jack’s surgery was scheduled I started the time consuming process of getting price estimates from the surgeon, anesthesiologist and the facility since we have a high deductible insurance plan. The physician fees were straight forward and relatively easy to obtain, not so with the facility. Jack’s surgery was scheduled at the local hospital’s outpatient surgical facility. I called the hospital to request a price for the surgery and they said they couldn’t really tell me. They offered to send the procedure codes to an external reviewer who would provide a general idea of the anticipated charges. Three days later the answer came back at $37,000. I reiterated that I had high deductible insurance and needed to know the actual price they would bill me after an insurance adjustment to the network fee schedule.
The hospital next referred me to my insurance company. The insurance company referred me to their PPO network. The PPO network said that they could not reveal the prices until after the case was performed. I called back to the hospital.
At this point the hospital said that they could not tell me how much the discounted price would be either and they also wouldn’t negotiate a cash price with me. They expected the discounted price to be in the range of $15,000 to $25,000. They also offered to limit my out of pocket portion to $10,000. I am now on day six with over a dozen phone calls; not the price I expected for a 2 hour outpatient procedure.
I asked my son’s surgeon if he ever operated at any independent Ambulatory Surgical Centers (ASC) and if so would that be an appropriate place to perform my son’s surgery. As it turns out there is an ASC in the ground floor of his office building and it would be no problem to do the surgery there. One phone call and 10 minutes later I have the exact price for his surgery- $1,515.
My son had his surgery and is doing well. We got a fair price because we demanded more of the system.
This simple surgery makes me pause to consider so many issues we face in our health care system. Why does it take days and dozens of phone calls to get pricing information from hospitals? Why can’t hospitals provide upfront prices for their services? Why do they expect to bill patients unknown amounts that they determine after patients have already received care? And what about the patients that don’t know the system. Would a patient facing a $40,000 bill delay or defer surgery when they might get the care they need if they were able to use the $1,500 center? Do they know to ask? No. Does anyone really help them? No.
And what about the healthcare providers. Why didn’t my son’s surgeon recommend the ASC in the first instance? Why hadn’t the surgeon done a single procedure in the ASC in over 2 years? At 10 cases per surgical day, at about $20,000 more per case; how much has this practice cost patients, employers and insurance companies? Millions each year for one surgeon and his patients?
It all goes back to our foundational problem with U.S. healthcare. The business model of our health care system is based on third-party payments from insurance and government. This has evolved to the point that many patients and providers don’t stop to consider why they shouldn’t spend $37,000 for something that could easily be delivered for $1,500.
It is not easy being a patient-consumer, but it can be done. Let’s hope the system moves in a direction that allows this to happen.
Monday, July 18, 2011
The following anecdote is by Alexander Friedman, MD, a fellow in maternal-fetal medicine at the University of Pennsylvania
My patient needed to be delivered. She had just developed eclampsia, a potentially fatal disease that afflicts women in the second half of pregnancy. She had suffered a seizure and dangerously high blood pressure, and was at risk for far worse, including a stroke. No one knows why this condition arises, but delivery sure clears it up in a hurry.
So we gave medication to start labor, and the nurses placed a fetal heart monitor.
Worn like a belt, but higher on the abdomen, the ultrasound monitor would play a crucial role in the hours to come. It prints a read-out strip of the baby's heart rate, and the pattern would guide us in determining whether the delivery would be natural or through cesarean section.
As I suspected, the baby's heart-rate strip showed worrisome changes soon after labor began, and I knew it would get worse as labor progressed. We would fight through the night to have a natural delivery. But ultimately that single heart-rate test, which is surprisingly unreliable, would be a key factor in whether my patient would get a C-section or not.
Nearly all American mothers are monitored during labor, and bad fetal heart strips are an important cause of high cesarean section rates. A recent report detailed the dizzying increases: Almost one in three babies was delivered by cesarean in 2007, the most recent year for which data are available. That rate has grown by more than 50 percent in a decade.
I have performed hundreds of cesarean sections during residency, and many were the result of bad heart-rate strips.
A jagged pattern indicating increases in the heart rate reassures us that the baby's brain is awake and alert, and that labor could continue. But a flat line or decreases in the heart rate after contractions make us think the baby is not getting enough oxygen and pushes us to do a C-section - delivering the baby through incisions in the abdominal wall and the uterus.
For the worst readings, we believed every second counted and rushed the surgery: If the baby wasn't delivered one minute from the first incision into the skin, we had moved too slowly.
The complication we feared most was hypoxia, the baby not getting enough oxygen during labor. Going too long without adequate oxygen could result in a serious permanent injury, such as cerebral palsy, or even death.
No test is perfect. But almost every time we whisked a mother back to the operating room, and I cut through skin, fat, fascia, and finally the muscle of the uterus, expecting a blue, floppy baby, the child I delivered emerged pink, healthy, and a little bit angry.
Were we saving lives and averting disaster? Or were we performing unnecessary surgery?
Fetal heart-rate monitoring is a screening test. Good tests get several things right; they are cheap, detect a possible problem when there is still time to act, and minimize unnecessary follow-up tests.
Fetal heart monitoring is an appallingly poor test. The test misses the majority of babies with cerebral palsy, the condition researchers hoped it would prevent. It causes increased rates of a painful and expensive surgery: cesarean section. Even worse, almost all women undergo continuous heart monitoring during labor, not just those at highest risk.
Why do doctors cling to continuous fetal heart monitoring? An obstetrician will likely point to the fear of being sued, but the complete answer is more complex. Our medical culture prizes technology and tests, even if they don't work and can cause harm. "It's our bias that anything that can be quantified is an improvement," said H. Gilbert Welch, a professor at Dartmouth Medical School whose research focuses on harm caused by screening and over-diagnosis.
"I think we get in trouble when we start promising things to . . . well [patients]," Welch said in an interview. "It is not that hard to make them worse."
Throughout the night, I struggled with my patient's bad fetal heart strip. I wanted her to avoid a cesarean section. To improve the strip, the nurses and I tried giving her oxygen, changing her position in the bed, even rubbing the baby's head through the cervix to wake it up.
Finally, at 3 a.m., I felt compelled to recommend cesarean. The strip continued to look bad, and my patient's labor progressed slowly.
We went to the operating room, and delivered the baby by cesarean. My patient's child greeted the world pink and well-oxygenated.
The test was wrong again.
Tuesday, July 5, 2011
Always covered by an employer health plan, I had never given a thought to prescription costs – my medications had been covered by moderate copays. This changed when I retired and enrolled in Medicare (and a Medicare Part D plan).
Just prior to retirement, my eyes suddenly began tear and swell so much that it impacted my vision. The eye doctor diagnosed an allergic reaction and prescribed prednisone drops to reduce the swelling and antihistamine drops to combat the reaction. The antihistamine drops required pre-approval by my employer’s PBM, which was granted. Per my employer plan I paid a relatively small copay for each prescription.
Three weeks later, on a follow-up visit, the doctor recommended that I continue the antihistamine drops for the duration of the allergy season. But I was running out and had to refill the prescription. Now I was on Medicare so I checked the cost of the drops on the website of my Part D provider. It was $279. Could this be?? Oh indeed it could -- and I had a high deductible and would have to pay all of it!! Of course, if I continued to need the drops, the plan would eventually assume more of the expense – but even then the cost would be high – to the plan, even though not as much would come from my own pocket.
I was somewhat puzzled. I did not have an exotic illness requiring a specialized drug and it seemed that there should be a less expensive alternative. After a conversation with my doctor, it turned out that there were, in fact, two reasonable options: one a prescription which was ½ the price of the current prescription; the other a medication that had previously been script-only, but was now available OTC – the cost for this was $14.79. He suggested that I experiment with the alternatives to see if they were as effective as the current drops. Fortunately, the $14.79 version was just fine. Of course, it might not have been, but it was. But had I not asked, it would not have been offered. And had I not had a plan that exposed the cost of the expensive prescription, I would not have asked.
A few weeks later, I had a similar experience while visiting my 92 year old mother. In response to a complaint about stomach pain, her doctor had prescribed an extremely costly medication. She was required to pay $80 for the first prescription and then $184 when she tried to renew it. She decided that it hadn't really helped much anyway and decided not to renew. But I realized that had the cost not been so high, she would have ordered it.
These two experiences led me to wonder about the impact of "hiding" medication costs from patients (as my employer plan had essentially done), and of doctors not being sensitive to cost issues until prodded by patients. Of course, sometimes the more expensive drug might well be necessary – but surely there must be many instances in which money could be saved by balancing therapeutic need and cost.
Monday, June 20, 2011
The following anecdote is by Dr. John Maa, Assistant Professor of Surgery at the University of California, San Francisco. It is a follow-up to his original story published here three months ago ("Ultimate Sacrifice"). You can also read the story of his mother in this week's New England Journal of Medicine ("The Waits that Matter").
My uncle’s tale illustrates the fundamentally American tragedy of experiencing financial and medical catastrophes simultaneously, and having to choose between rationing one’s own care or depleting precious financial resources for potentially lifesaving treatment that could as well be futile.
From my perspective as a surgeon, an additional tragedy is that my uncle never got the chance to know his cause of death with certainty. There is a small chance (approximately 5 percent) that his jaundice arose from a benign or treatable condition such as lymphoma, an autoimmune process, or another noncancerous condition, and that if he had received full treatment he would be alive and well today. But a diagnostic surgery would likely have added $100,000 to his final medical costs. Thus my uncle weighed the odds and rationed his own care to preserve his daughters’ inheritance for their future benefit.
To answer the question I posed at the end of the previous article, I do not believe that my uncle was treated fairly by the system. Sadly, he was just a few years too young to receive Medicare benefits, despite having paid into the system for decades. I was especially struck by the feedback about my uncle’s story from readers in France, Poland, Canada, Cyprus, and other countries with universal health care who were stunned to read of the dreadful timing in this desperate situation.
Only in the American employment-linked health insurance system does the loss of job also bring with it a loss in access to health care. The special irony is that my uncle had actually just become employed as an independent contractor a few weeks before falling ill. He thus had not felt the need to purchase COBRA as he hoped to soon receive health benefits. His charity care application had been denied as he was employed when he fell ill and had truthfully reported his future inheritance from his mother (even though he would not have access to it for over a year). Given these assets, he likely would not have qualified for Medicaid either.
In 2000, the WHO rated health systems worldwide. The most interesting aspect of this report was the methodology. One fourth of the ranking was dependent on the concept of “financial fairness”, with the ideal that the system be progressive, wherein wealthier people would pay a higher percentage of their income for healthcare than poorer people. Instead, the way Americans pay for healthcare is actually the opposite of the ideal championed by the WHO. The underinsured and poor pay a higher proportion of their household income for health insurance and are particularly vulnerable to bankruptcy from medical illnesses, while wealthier people are more likely to receive tax free complete health coverage as a benefit of employment.
Except for patients who require dialysis or develop certain disabilities, Medicare is generally an all or nothing proposition, with the magic threshold at 65 years of age. According to the Medicare website, “Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years or older and a citizen or permanent resident of the United States.”
Between joining the workforce at age 25 and retiring at age 65, many Americans will make Medicare payments for many years beyond the mandatory 10- year requirement. No credit is given to people like my uncle, who pay into the system for decades but fall ill before the age of 65, whereas pitfalls and loopholes in the current Medicare system cover others who never paid into the system at all.
I observed one such loophole during my time working as a general surgeon at a county medical facility serving the indigent population in California. Not infrequently, I witnessed “medical travelers” with kidney failure who came to the United States from other countries, where dialysis was no longer offered to them cost-free after the age of 65, thereby requiring them to pay out of pocket. These patients would apply for “emergency” Medicare in the U.S. to continue life-saving dialysis that they could not afford in their own countries. In other instances, patients actually possess sizable financial assets but conceal them by giving these away to their children or not reporting these truthfully (unlike my uncle) to qualify for charity care or meet Medicare eligibility requirements.
It is hardly news that the existing Medicare scheme already includes an element of rationing by limiting the number of Medicare inpatient and long-term care days a person can receive. Our nation has yet to meaningfully discuss end of life care and the potential solutions by setting a budget to overall spending, but starting this discussion will inevitably become necessary.
In 2010, Medicare had 47 million beneficiaries or 15.3% of the total population. In 1965, there were 19 million enrollees (9% of the total US population). This increase is partly due to the significantly greater life expectancy (age 70 in 1965 to age 79 in 2011) achieved by the successes of the American health care delivery system. This more than doubling of the number of recipients is a contributory factor to the looming insolvency of Medicare.
An alternate construct might be for individuals to accumulate a budget of health care benefits for personal use that varies according to the contributions they made into the Medicare system over their lifetime, and is available regardless of the age at which they would like to make withdrawals. Perhaps this individual allocation could be supplemented by a fixed baseline contribution from the government, which we could place in the range of $20,000. In this alternate world, medical prices and costs would be completely transparent, and the patient (or decision-maker if the patient is incapacitated) could choose from a menu of options for how aggressively to spend this allocation, recognizing that if they exceed the budget is exceeded then he or she must pay the balance on their own. Luxuries and optional care will either deplete the budget, or be paid for out of pocket. The concept of personal responsibility and taking care of one’s health will be reinforced in this scheme, though an adjustment must be made for those who fall ill to diseases that are the result of bad luck and circumstances beyond their control. Perhaps an individual can even choose to opt out of the program (as my uncle would have done), to be able to save some fraction of the remaining balance as an inheritance for his or her descendants.
Equally important, this mechanism may drive health care prices down, as purchasers will be motivated to be frugal and educated, rather than ignorant, of the true costs of care, while providers, hospitals and manufacturers will need to lower prices as they compete for business.
I discovered the Costs of Care essay competition while researching the key difference between the “costs of care”, and the “price of care”. The two are quite distinct, and have been fundamentally misunderstood in the health reform debate. In addition to “bending the cost curve”, our nation should seek to “bend the price curve” through a deeper understanding and transparency into how the health care industry sets the prices of medical care in America.
Ultimately, my goal in writing this essay is to assist in reframing the national dialogue about health reform. The debate about rationing of health care should not simply be about the extremes of either denying access to all care, or allowing unlimited access to full treatment. Instead the time has arrived for our nation to intelligently explore the full range of possible solutions in between.
Epilogue: I celebrated the two year anniversary of my uncle’s passing by visiting the long term care facility where he spent his final days. I was impressed by several visible changes for the better (new services, a higher occupancy, social programs, and a refurbished lounge for residents). It gave me hope that progress is possible. My uncle’s younger daughter will begin college in Pennsylvania this fall. His elder daughter graduated with honors from college in May 2011 and will begin work in Manhattan over the summer. At her commencement, a video was played from freshman week four years earlier, and footage of my uncle that our family had never seen before was displayed to all of the graduating seniors. Despite making the ultimate sacrifice, my uncle’s presence was palpable at the celebration, and his intent fulfilled.
Sunday, June 5, 2011
Ian Metzler is a medical student at Harvard Medical School, currently studying health systems improvement at Children's Hospital Boston.
With computerized health systems, physicians can place orders as easily as they can shop online at Amazon.com. Just a few clicks and your physician can purchase a panel of blood tests, futuristic imaging and diagnostic procedures that will hopefully guide their path to solving your ailments.
Search. Click. Submit. Repeat.
Except, unlike online shopping, physicians don’t see the price tags and they never get the bill. Doctors are the true consumers of health care dollars, but the rules of economics falter when the consumers aren’t the ones that pay up. This disconnect is a fundamental cause of the uncontrollable inflation of health care costs in the US. Ignorance about cost fuels spiraling inflation in healthcare because without cost-related restraint in utilization there is no incentive for suppliers of healthcare services to get any cheaper.
But the system’s stuck. While physicians ultimately control the tap of healthcare costs, exerting that control can contradict their primary objectives. Physicians feel a responsibility to do the most they can to make the patient in front of them better. If young doctors don’t order a test, a superior may berate them for not considering it in their differential. Malpractice always lingers as a consequence for a diagnosis missed. Some claim that it is irresponsible or unethical for physicians to consider cost in their clinical decision making. Perhaps good doctoring should be blind to finances. And after all, it’s no skin off the doc’s back to just click a little more, some of that money may even end up back in their own pockets.
Despite all these pressures pushing physicians to just do everything imaginable, many realize that physicians also have a responsibility to balance the health of the individual and the health of the community. No matter how much we try to ignore it, health care is a limited resource and giving more to one inevitably means less for another. In Cooke’s 2010 NEJM article on cost-consciousness in medical education she writes, “[We must] stop hiding behind the myth that every physician should and does apply every resource in unlimited degree to every patient for even minimal potential benefit”. The reality is, physicians already dictate how finite resources are allocated in the hospital. Physicians decide who gets how much of their time, who deserves a consult from a specialist and who should be in an ICU bed. Why don’t physicians exhibit the same judgment and restraint for expensive tests and imaging studies? Cost-consciousness at this scale may be beyond human cognitive capacity, especially when competing with disease differentials and medication lists. It’s far easier to count down the hours in the day and notice when all the ICU beds on one wing are full than to be mindful of the obscure strings of digits and commas that represent their health care spending. The finances of health care are far less visible but just as real.
While respect is growing for skyrocketing health care costs, the average doctor is clueless about the price tag of their day-to-day clinical shopping-sprees. In a 2008 review of 14 studies, Allan et al. found that doctors came up with estimates that were within 25% of the true cost of diagnostic tests less than one-third of the time. And, interestingly, they found that the country, level of training, and specialty of those surveyed did not impact accuracy. This tells us a few things: doctors have no idea how much they’re spending for their patients, it’s not just US doctors or super-specialists who are clueless, and most importantly, it doesn’t get better the farther along young docs get in their training. The Chief of Medicine who can diagnose Peutz–Jeghers syndrome from across the room may have no idea how much it costs to do a colonoscopy or a genetic workup for the patient. It’s not just students who are naïve and, sadly, financial insight doesn’t come with time.
For our generation, this deficit threatens to spin out of control. The stakes rise as physicians become capable of doing more and more for each and every bullet point on their differential diagnosis. Immunoassays and genetic tests are available for the obscurest pathologies. Imaging technology can produce increasingly fantastic windows into the human body. But as these options become more numerous and specialized, our grasp on what’s necessary to produce quality care only slips further.
If cost-consciousness among physicians is the goal, how do we achieve it? Competition for doctor’s time and brain-space is fierce. Cooke thinks that health finance should be integrated into medical school curriculum from the start. Educators suggest dual-degrees in business. Researchers have tried post-graduate education campaigns. Hospitals try to intervene with computerized decision-support systems. Insurance companies stall with mandatory pre-authorizations. But few interventions have shown substantial increases in awareness of cost or changes in physician behavior.
Health information technology (IT) may be partly contributing to the ease of over-zealous ordering, but it may also hold the potential to curb it. Two large randomized controlled trials conducted at a large teaching hospital attempted to show that the inclusion of costs in the ordering system itself might increase awareness of physicians and decrease the over-utilization of diagnostic laboratory tests and radiological imaging. Although it was conducted over four months and involved over 24,000 patients, the study showed a statistically insignificant 4.5% decrease in the number of laboratory tests ordered and almost identical rates in the number of imaging studies ordered. The authors concluded that more intrusive measures were needed in order to affect change, like prompts similar to those in decision-support. Price tags alone weren’t enough.
Ultimately, the judicious and cost-effective utilization of limited health care resources remains a physician’s responsibility. They’re trained to make clinical decisions and manage treatment plans but those same decisions dictate the finances of patients and the health sector as a whole. These dual roles are inseparable and increasingly consequential yet the majority of physicians are too unaware or unprepared to meaningfully incorporate financial consequences into clinical decision-making. Any efforts to reform health care policy to reduce costs and spend our health care dollars more efficiently and equitably must start with assisting doctors make better and more informed decisions for their patients. Physicians must wake up to the reality of modern medical practice and start educating themselves about the economics of their patient care methods and they must demand the information when it’s lacking. This will require a culture shift in how medicine is practiced and future generations of doctors are trained. In a world of competing priorities and information overload, physicians will need help. More cost-effectiveness data is needed so that physicians have an evidence base for rational allocation of resources. Health IT, decision-support, payment reform and institutional leadership are all essential strategies to encourage cost-consciousness and appropriate health care spending, but none can be effective in isolation. The tap of health care dollars that threatens to run dry is controlled by thousands of physicians and their daily interactions with unique patients. Only through innovative programs and education campaigns can we reduce the flow of excessive health care spending and help physicians avoid irresponsible clinical shopping sprees and begin to make evidence-based decisions with a broader context in mind.
1. Cooke M. Cost consciousness in patient care -- what is medical education's responsibility? N Engl J Med 2010;362:1253-1255
2. Abbo ED, Volandes AE. Teaching residents to consider costs in medical decision making. Am J Bioeth 2006;6:33-34
3. Goold SD, and Stern DT. Ethics and professionalism: What does a resident need to learn? American Journal of Bioethics. 2006. 6(4): 9–17.
4. Allan GM, Lexchin J, Wiebe N. Physician awareness of drug cost: a systematic review. PLoS Med. 2007;4(9):e283.
5. Allan GM, Lexchin J (2008) Physician Awareness of Diagnostic and Non-drug Therapeutic Costs: A Systematic Review. Int J Technol Assess Health Care 24: 158–65
6. Bates et al. Does the computerized display of charges affect inpatient ancillary test utilization? Arch Intern Med. 1997;157(21):2501-2508.
Monday, May 16, 2011
How much will a visit to the doctor’s office cost? It’s a seemingly simple yet perplexing question for both patients and physicians. A fundamental problem continues to be that patients and physicians do not readily have access to the expected costs of care, from lab tests to MRIs to outpatient surgical procedures. Today’s complex medical reimbursement structure makes this information elusive, in turn limiting physicians’ abilities to have a transparent discussion with patients about the impact of clinical choices on their out-of-pocket costs. While the need for transparency is nearly universally accepted, the questions of who should make this information readily accessible and how we get there have yet to be settled.
Why are estimates for care so elusive?
Simply put, medical bills are complicated. There are two key factors which determine an insured patient’s responsibility for a medical bill: what their insurance company has agreed to pay the doctor, and what their specific plan benefits include, from their deductible to coverage for specific types of procedures. Additionally, the provider’s charge structure is relevant for uninsured patients, but has little bearing in the ultimate patient responsibility for most insured patients.
The first question alone, what the insurance company has agreed to pay the doctor, is not easy to answer. Every insurance company negotiates separate contracts with each provider, and these agreements are challenging to interpret and “translate” into software accessible by medical staff or physicians due to the many unique exceptions and rules.
The question of the patient’s plan benefits can be even more challenging to answer: each insurance plan can have different deductibles and policies, and the patient often doesn’t know the status of their benefits. Do you know your deductible balance at this moment?
Coupling these two pieces of information quickly, and the time of service when a physician is with a patient, can be daunting.
There are some alternatives to providing a precise estimate to the patient. One alternative is a simple price list akin to a “rack rate” at hotels, or a generalized estimate regardless of the patient’s insurance company or benefits. Some organizations have chosen to post their charges online, but they are unfortunately not reflective of what the insurance companies actually pay and ultimately become a patient’s responsibility.
This all begs the question: who ultimately should be responsible for providing this information, accurately, to patients?
Who can deliver?
The most convenient answer has usually been that it is the patient’s responsibility to determine what their service will cost. This belief has spawned a number of websites, most of whom use some variation of freely available Medicare data, to deliver a generalized estimate of payments for care. This approach makes two leaps of faith – first, that patients will take the initiative to research healthcare prices, and second, that it is good enough to know a regional or national average instead of a precise, customized answer.
The next group, insurance companies, have made some strides in price transparency. The trend, however, is for insurers’ patient portals to not specify their rates for specific physicians, but rather use regional estimations. Furthermore, this information is non-standard, and usually only available to patients (and the more web-savvy ones at that), not others in the industry.
That leaves us with the providers as the ideal group to enable price transparency. The physician-patient relationship is the base for the entire healthcare system, and layering the cost dialogue into that existing, trusted discussion stands to reason. Physicians and other providers sit in the unique position of being able to translate pricing questions for patients into a language that makes sense in the context of the care delivery model. If correctly enabled, this could change the way physicians and patients approach medical decisions about the benefits of performing services that may have marginally more benefit for disproportionately higher costs.
So, how can they do it?
Some of the rudimentary methods above – using base charges, some variation of Medicare pricing, or payer-driven information – can be serviceable in limited situations, but not ideal in today’s more demanding, high-deductible environment. Practice Management Systems have made limited progress in the price transparency areas, but their offerings tend to work best in the most basic situations when intuitive user interfaces are not required.
Fortunately, as technology improves, recent advancements are opening new doors. For example, MD Clarity’s web-based software can be delivered as a service via the web and mobile devices to make accurate information available within seconds rather than spending unnecessary time tracking it down or, worse yet, settling for data that isn’t entirely accurate. The newest, most sophisticated software combines payer-and-plan-specific information for results that are completed customized to the provider’s practice and the patient they are dealing with. Most of all, this complex software puts the price transparency discussion squarely within the physician-patient relationship where it belongs.
Mike Albainy is a Founder of Minneapolis-based MD Clarity, a firm providing web-based solutions enabling physicians and their staffs to provide accurate patient price estimates. The software allows physicians and office staff to confidently engage in a more informed dialogue about the cost and benefit of medical service options.
Friday, May 6, 2011
Tests and a physical examination made clear that an operation was unavoidable. The doctor was a thoughtful man who conscientiously went through what the operation would entail. Surgery would take half a day, then back home by afternoon, convalescence over the following few weeks, with complete recovery the usual outcome. While not painless, the procedure seemed reassuringly routine. His tone was caring and his outlook about our case optimistic.
The admirable candor with which medical personnel have learned to speak about difficult topics concerning our bodies and our care did not extend to the costs involved. The question of what the procedure would cost, gently broached, initially baffled the staff, eliciting answer-deflecting counter-questions about the adequacy of our insurance coverage, but resulted in no quotes or estimates. With my insistence on the point, an assistant promised that a figure could be determined, if we needed it, once the surgery was scheduled. “But not before?” I was now the baffled one.
A person who linked dollar amounts to medical procedures was eventually found and I was seated at her desk. She required a billing code however, and without a scheduled surgery there was none to offer. As we danced around that issue, my concern over the cost of repairing A.’s knee was replaced by another curiosity: “Is what I’m asking not routine?” It was not. A billing code was finally lifted from the paperwork of a previous operation, and after some minutes a dollar number was produced. It was a sizeable figure, but less than what I’d been led to believe such things cost, at least in the United States. I suspected something still was not clear. “This is then what I’ll pay, roughly, to have the procedure done?” I asked in a half questioning, half confirming tone. “No, that’s just our part of it, the hospital has their charges, of course.” “But we’re in the hospital and I’m asking you for an estimate of what this operation will cost.” She explained, with some frustration, that the operation itself was only a fraction of the pie; she had no way of knowing what the hospital might charge.
This was not actually true – she was far better situated than I to know what the hospital charges would be. It was if I had asked for the price of a new car on a showroom floor and had been told by the car salesman that only the engine could be quoted – other components’ prices would need to be discovered separately, by me. In the real world, the total price for most services and products are conveyed to the consumer by the seller or provider at the end of a long chain of added values. In this case, the multiple components of the medical care provided a shield to simultaneously obscure the cost and justify its lack of availability. The billing person scribbled down a number for me to call, then asked if there was any other matter where she could be of assistance.
Hoping for a face-to-face conversation, I asked at the hospital information desk for directions to the office matching the telephone number scribbled on the scrap of paper. “That’s not in the hospital”, the information desk attendant declared, “but the call is toll-free”. We went home. For some reason, the inability to locate a price anywhere on the hospital premises for an operation that would take place there shook us as much as would have an encounter with a manifestly incompetent doctor. Though A. and I talked only briefly of the cost, or rather the opaqueness of it, we were both invaded with a foreboding that a thing so untethered to its own cost would be in some unspoken way unreliable, dangerous. That night, A. announced that she wanted to do the procedure overseas . . . anywhere but here.
Tuesday, April 12, 2011
The following anecdote is from Kimberly Seelye, a patient and a graduate student at the University of Michigan
Last July, I found myself needing to visit a doctor for an urgent medical issue. My period had started in April and never stopped. It was light, so it wasn’t too much of an annoyance, but after three months I figured I needed professional help.
I had started graduate school in Michigan the year before and was back home in California for the summer. I wasn’t sure if the new insurance that I paid over $2,000 per year for through the school would cover a doctor’s visit in a different state. I called the insurance company to check and they said they cover any doctor in the country. Happy to hear this, I called and made an appointment with the doctor I had been seeing for years.
Though my insurance had changed, my doctor’s appointment was the same as always, I just had a slightly higher co‐pay. I had a routine check‐up and the doctor ordered some blood tests to help diagnose my problem. Within a few weeks, the doctors figured out what was wrong and cured it. I returned to school in September happy and healthy. As far as I knew, my business with the doctor was finished.
While in California for the summer I didn’t have a permanent address. I stayed with friends for a few weeks at a time and house‐sat for other friends while they were on vacation. This arrangement allowed me to live cheaply for the summer and save money for school. However, when the doctor’s office asked for a local address, I didn’t have one. I gave them the address of a good friend I was staying with, figuring my friend would tell me if mail arrived for me at her house. Although I wasn’t expecting to receive any mail, I tried to have my mail forwarded to my school address at the end of summer, just to be safe. The Postal Service said they were unable to forward my mail because my school address was considered a business address and they don’t forward from residential addresses to business addresses. This frustrated me, but as I said, I wasn’t expecting any mail anyway.
Around October I received a call from a representative of the doctor’s office saying I had an unpaid bill in the amount of around $100. I told her that I had moved back to Michigan and never received a bill. She said she understood. She allowed me to pay my bill over the phone with a credit card and updated my address in her files. A week later I received a voicemail about an unpaid bill from the same office and dismissed it; I had just paid my bill a week earlier.
In November the friend I had stayed with in California informed me that she had a stack of mail for me that she had forgotten about and would send it right away. When I got this mail, I saw that there were several copies of an unpaid bill from the doctor in the amount of $1,500, and they were threatening to send my account to a collection agency. I was shocked and horrified. I didn’t have $1,500, so I couldn’t pay it. I was also heading into finals season at school, so I didn’t have much time to sit around and think about what to do with this bill.
A few months later I got a letter from a collection agency saying that I now owed them $1,500. I realized I couldn’t ignore the bill any longer and called my doctor’s office. A representative at the office told me the bill was for blood tests and mailed me an itemized bill, which had never previously been sent to me at any address. She also said that my insurance should have paid for it and that I should ask them about it. I called the insurance company and they said that my plan “doesn’t include all diagnostic tests.” So that was that. I was stuck with this $1,500 bill that I never saw coming and couldn’t pay.
As a graduate student, 100% of my income was student loans. Financial aid very specifically only covers school expenses and minimal living expenses, including my health insurance premiums. However, there isn’t an “unexpected, huge, medical bills” line in my financial aid award. No amount of frugal living would have allowed me to pay this bill. How else should I have handled this situation? Would I have been better off just bleeding indefinitely?
Monday, March 21, 2011
The following anecdote is by Samuel Yang, a patient from Maryland.
Up until last May, my experience of medical costs was limited to the $100 per month premium I contributed towards my employer-sponsored insurance and the nominal co-pays associated with well-child checkups and generic prescriptions. There was never any hesitation in seeing a doctor or filling a prescription. That all changed when went I back to school.
I blindly signed up for the school-recommended family insurance and naïvely assumed myself, my wife, and my two young children would receive whatever health care we needed at a relatively small co-pay. The upfront premium of $10,000 was high, but I believed that this would cover whatever life threw at us. However, two experiences woke me up from my ignorance: my wife's endoscopy and a visit to the pediatrician.
In July, my wife was sent by her doctor to get an endoscopy to determine the cause of her stomach pain. In the weeks following her procedure, we started receiving statements from our insurance company. The statements declared that we were responsible for the full amount. We received the following explanation from our insurance company, “We don't cover preexisting conditions.” As we argued with the insurance company, the hospital bills started trickling in: $1200 from the outpatient center, $200 from our family physician, $400 for the anesthesiologist and $200 from the lab. We received six bills demanding $2600 for one procedure. As I examined the bills I was shocked by the redundancy—why is the cost for the anesthesiologist not included in the outpatient center bill? Why do I need to pay my family physician twice (the initial visit and the follow-up) for a procedure she ordered us to do? Besides feeling hung-out-to-dry by my insurance company, I felt taken advantage of by the medical system. It seemed as if everyone in that hospital wanted to include something for our visit. After fighting tooth and nail to get our insurance to cover my wife's endoscopy, they finally relented. Still, we were left with $700 to pay. For an unemployed student, $700 is not a small co-pay.
I studied the coverage booklet put out by my insurance, and I still do not understand what is covered and what is not. What I found was something similar to how we were billed for my wife's endoscopy: the procedure itself is covered one way, labs are handled another way, and prescriptions are an entirely different matter. How am I supposed to know what labs or prescriptions are associated with an endoscopy?
Compared to my wife’s endoscopy, my daughter’s first visit to the pediatrician should have been straightforward. A fever that lasted three days followed by a rash was a simple diagnosis for her experienced pediatrician. What is not simple is the billing and insurance struggles we are facing. Our insurance company decided that my daughter's fever was a preexisting condition, and as we fought with them to fulfill their responsibility, the pediatrician's office contacted us that the $115 fee is actually $321. Again, the feeling of being taken advantage of is overwhelming. It could be that our doctor's office is honest in their error, but I have never received services or products charged to me like this. In other words, when I go to the store, I know exactly how much a pound of apples will be long before I get to the cashier—and there are no “preexisting” conditions that add hidden costs at the register.
I've learned a lot about medical cost of care; that is, care costs a lot and it's not straightforward what the cost is. I know that we have paid $11,021 for an endoscopy, a visit to the pediatrician and spotty coverage for the rest of the year. It’s not merely that medical care is expensive, it’s also that I have no estimate of what my costs will be. Getting new brakes on my car is expensive, but the mechanic is very careful to give me an itemized estimate before the repair is made. Recently, my wife, after a particularly exhausting week, started experiencing pain in her chest and a tingling sensation in her arm. Being a nurse, she knew exactly the tests that would be ordered if she went into the hospital.
Despite my attempts, she refused to go to urgent care knowing that the cost of the visit, even if our insurance company cooperated, would be enormous. There's now a hesitation to use our medical resources that was never there before.
Saturday, March 5, 2011
The following anecdote is from Dr. John Maa, Assistant Professor of Surgery at the University of California, San Francisco
An estimated 60% of American bankruptcies result from overwhelming medical costs. My uncle’s tale illuminates the dual tragedy of suffering catastrophic illness and being uninsured.
The 2008 recession claimed my uncle’s job, health benefits, and assets, except for a small inheritance. By 2009 he found work (but not health coverage) as a consultant.
One day he noticed that his eyes were yellow. He emailed a photograph, and I immediately recognized jaundice. I calmed him by suggesting benign causes such as hepatitis, gallstones, or liver cirrhosis. But I secretly dreaded a liver or pancreas cancer, given his recent weight loss and itching.
Laboratory and x‐ray tests, which he charged to his credit card, all suggested cancer. His doctor in New Jersey indicated urgent surgery was necessary. An appointment was unavailable for weeks at the county hospital, and private surgeons wouldn’t see him without a cash deposit. Time was ticking. Cure was already unlikely, and delays were allowing the tumor to grow. He decided to travel to the West Coast to expedite surgery.
My uncle arrived around midnight, glowing yellow; he had worn sunglasses to avoid frightening other airline passengers. He was immediately admitted to undergo a procedure to identify the site of blockage and insert a plastic stent to drain bile externally. While awaiting the outcome, I had a premonition that the worst was yet to come. The doctors brought dreadful news that a massive tumor, too large to remove surgically, lay centrally in the liver. The remote possibility existed of a benign condition masquerading as cancer. The aggressive option was upfront chemotherapy and radiation to shrink the tumor, for possible surgery afterwards. But several surgeons deemed the case hopeless, and estimated my uncle had only 6 months to live. They recommended hospice, and a more comfortable internal metal stent. My family chose not to share these findings with my uncle until he recovered from anesthesia.
The crushing blows continued. Within 36 hours, my uncle lapsed into a coma from kidney failure induced by bile toxins. Knowing the costs, we refused transfer to the ICU. Dialysis was necessary, but the nephrologists regarded the situation futile and refused treatment, comforting us that dying from kidney failure was painless. Miraculously, he rallied. Seeing improvement, the nephrologists started dialysis. We could finally share with my uncle the difficult choices ahead.
He responded “It’s hopeless. Why risk money that could provide my daughters’ education?” He asked to be made “do not resuscitate”, and declined surgery. Two weeks of recuperation made transfer to less expensive skilled nursing care possible, but here I learned it takes money to save money. Ambulance transport was mandatory, costing $1700. As I read the dispatcher my credit card information, I wondered if I could have driven him myself.
In the following days, we tried everything to minimize costs. My uncle had a fever, but refused evaluation in the ER, and was treated with blankets and oral antibiotics. His fever broke, as did the stitches on his stent, which I re‐sutured at the bedside.
In the end, my uncle made the ultimate sacrifice for his daughters by rationing his care. Death came swiftly, only 72 days after he became jaundiced. He never received metal stents, or saw New Jersey again.
His final medical bills totaled over $250,000. Charity care was denied, and MediCal unavailable since he was from out of state. After receiving a 20% discount for paying in a lump sum and in cash, we negotiated a final 40% discount.
The costs of his care can be translated as follows. Each session of dialysis equaled a month of private college tuition. Each day’s blood work would have provided a year of textbooks. The daily hospital room charge would pay for a half‐year in the dormitory. The anesthesia fee would have purchased a full year’s meal plan.
My uncle’s cause of death remains unknown. Weeks into treatment, his tumor markers came back normal. Surgery might have been curative, or confirmed a hopeless situation. The cost to know with certainty would have consumed his inheritance. The World Health Organization recognizes this universal tragedy worldwide: “The poor are treated with less respect and given less choice of providers. In trying to buy health from their own pockets, they pay and become poorer.”
Whenever someone faults the medical system for the epidemic of bankruptcies, I ask instead: My uncle was 59, and for decades had contributed to the system by paying health insurance premiums while employed. Did the system treat him fairly when he needed care?