Doctors, Not Financial Engineers

The following anecdote was written by Dr. Andrew Schutzbank, a physician in Boston who was among the winners of the 2011 Costs of Care Essay Contest.

Peggy was in her early 70s and suffered from a terrible lung disease known as pulmonary hypertension. So bad in fact, that she had a pump infusing a medicine under her skin 24 hours a day to keep the blood supply to her lungs open. Once started, this medicine, treprostinil, was known to improve life in those with pulmonary hypertension. Unfortunately, like all continuous infusion medicines of this type, it has the unfortunate side effect of sudden death if stopped for more than 4 hours. Starting it was a difficult choice for Peggy and her expert team of physicians, but her disease had progressed to a point where it was the right decision. As you can imagine, this drug was mighty expensive. We would only find out how expensive later.

On the day that I met Peggy, she was being admitted to the Intensive Care Unit (ICU) not for her pulmonary hypertension, but because she had a bleed in her stomach, which caused her to swallow blood/stomach contents into her already damaged lungs. Once stabilized, our first challenge was to ensure that she continued on the treprostinil. It took a little magic from pharmacy and the drug’s manufacturer, but we were able to get everything together and Peggy was no worse for the wear.

A few days later Peggy was improving, breathing tube out and awake and back to herself. Due to the special nursing needs with treprostinil, Peggy was required to be in the Cardiac Care Unit (CCU), a special type of (ICU), despite her progress. Even though Peggy managed this medicine at home by herself, hospital policy prevented her from transitioning out of the ICU to the general medical floor, at a fraction of the cost. Conceding that point, the decision was made to try and transition Peggy directly to Rehab. But her progress was stalled for one simple reason: treprostinil.

It turns out that if Peggy were to go to a rehab, they have to pay for her medications out of the money they receive to care for her. As it turns out, treprostinil costs $1400 per day. $1400. Now, Peggy does not pay that amount, she has a special arrangement worked out with the company and the state. But in order to make that arrangement work, the company charges full freight for the drug when the patient is institutionalized. Since the drug cost alone would wipe out payment for her stay, no rehab would accept her. So Peggy was stuck in the hospital, and stuck in one of the most specialized and expensive beds in the hospital in the CCU.

Think about that for a moment. A critical care bed was tied up for days for a patient that was well enough to leave the hospital, just not ready to go home. Arbitrage was suggested—would it not make more sense for our hospital to buy the drug for her at rehab, freeing up the CCU bed (which costs far more than daily dose of treprostinil). But we are doctors, not financial engineers. We work in the world of medicines and were unable to orchestrate such an unusual arrangement. So we did the only thing we know how to do. We stopped the expensive medicine.

This was not a financial decision. Peggy had been describing vague body pain, a known side effect of all prostaglandin medicines. Think of treprostinil as a 24-hour infusion of anti-Ibuprofen. Her breathing was actually quite good despite her recent trials in the hospital, so stopping the medicine made medical sense. We monitored her closely during the transition and she quickly improved! She was able to move around more and started on recovery. She was transitioned to a rehab shortly thereafter and continued to improve.

My colleagues’ decision to stop treprostinil was a medical one. But ironically, we would not have considered it if were not for the cost factor of the medicine. Peggy would have gone on for some time on an expensive medicine that was not helping her. At the same time, it was through one party’s insane attempt to “control costs” that simply caused costs to be shifted and multiplied. The entire health care system spent much more on Peggy’s care because no one had the vision or authority to deal with $1400 a day. Pennies compared to the amount wasted, and nothing compared to the risk undertaken by Peggy and her family during this trying time.

Questioning the Price

The following anecdote was written by Court Nederveld, a patient from Florida who was was among the winners of the 2011 Costs of Care Essay Contest.

Hypertension was the trigger that forced medical cost awareness to the forefront. My doctor decided that with my rise in blood pressure it would be prudent to prescribe a blood pressure medication and order a nuclear stress test. With only a catastrophic insurance policy and a $5000 deductible it was imperative for my financial health to know the cost of both the drugs and the procedure up front.

The prescription was the first thing we faced. The script for Lotrel was written and a trip to the pharmacy revealed an out of pocket cost of $200 for a thirty day supply. This was way beyond my means especially factoring in that this drug would most likely be required indefinitely. Relating this information to the doctor resulted in a prescription for the generic Norvasc and the pharmacy cost was to be $138 for 30 days. Still beyond household finances. I then began to research Lotrel and Norvasc and discovered that they are two old blood pressure medicines, amlodipine besylate and benazepril hydrochloride. I requested that my doctor write the script for these two separate drugs and I now take them daily at a cost of $7 for a thirty day supply of both drugs.

Having successfully challenged the cost of prescriptions my eyes were wide open as I began the quest for a nuclear stress test. My doctor, fully aware that I would be a self-pay referred me to a colleague in our area. A phone call began with introductions, but then I quickly explained I would be a self-pay patient and needed to know the cost of the procedure beforehand. The doctor was unable to immediately provide a cost and after checking with staff requested $2500. I reminded him that I was paying out of pocket. He replied that it could be done for $1900.

I told the doctor that I wanted to be sure I understood. I asked, “if I walked in with a check for that amount I would walk out with the test results?” The physician responded that I would need to come in for a consultation first. Cost $250. I asked again, “if I walked in with $2150 would I walk out with the test results?” Again the reply was that there would have to be a follow up visit to review the results. Cost $250. Hesitation must have been detected in my voice or the doctor detected a possible mark, because the doctor then said that perhaps I didn’t need a nuclear stress test and a regular stress test would suffice. Cost $800.

Consultation and follow up not included. I then asked what would occur if the regular stress test revealed nothing. His response was that we would do the nuclear stress test to be sure. The inverse was also true; if the regular stress test revealed any anomaly then a nuclear stress test would be ordered to provide further information. Total cost out of pocket would be $3450.

Feeling much like a cow on a milking machine I began to test the theory that medical procedures should be available as a commodity. Using the Internet to begin my search, the only specific criteria required was that the location of the facility performing the test be within a short drive from home. It took very little time to find and confirm a company that would provide a nuclear stress test sans consultation, and would willingly and promptly forward the results to my primary care physician. To verify that all was understood I informed them that I would have a check for the exact amount they quoted and no further remuneration would be forthcoming. All was as stated and the procedure was done. Total cost was $938.11.

While these two episodes have been the only challenges faced so far, having related these stories to friends and family, they also have begun to challenge costs and procedures with very similar savings.

It will be several years before Medicare is available to me and until that time I intend to challenge every prescription or procedure as to necessity and cost.

Treating Heart Failure on a $100 Budget

The following anecdote is written by Molly Kantor, a medical student from Boston who was among the winners of the 2011 Costs of Care Essay Contest.

As a third year medical student, I spent one afternoon each week at a health clinic at a community hospital affiliated with my medical school. This health clinic was focused on primary care for patients with HIV, and many of our patients were poor, homeless, immigrants, or uninsured. Many were also living with their diagnosis in secrecy and had to hide their medications and medical bills from family members.

One of my patients, who I will call Clara, was a 65 year old Haitian immigrant who diabetes, heart failure, and depression, along with HIV. Due to her medical conditions, she was unable to work. She had two grown children, but they did not live nearby and did not know about her medical problems, especially her HIV. Her husband, unfortunately, was very ill and lived in a nursing home. Clara somehow managed on her own, but her lack of insurance, poor medical literacy, and limited English proficiency made it difficult for her to stay healthy, and she was constantly coming to clinic for help.

At one visit, Clara seemed unusually tired and revealed that she had been feeling short of breath at home. In my mind, this raised many questions—Could this be a heart attack? Worsening heart failure? A blood clot in her lungs? Pneumonia? I took a history and did a physical exam, and my top concern was that this was an episode of worsening heart failure, what we call a heart failure exacerbation, and this typically occurs because the body accumulates too much fluid that the heart has trouble pumping it all so it backs up into the lungs.

Usually, this is a patient who you would send to the Emergency Room (ER) and have them admitted to the hospital so that they could get diuretics (water pills) and slowly lose the extra water—all while being carefully monitored in the hospital. However, Clara refused to go to the ER. “Too expensive,” she stated firmly. “I can’t go into the hospital again.”

We realized the burden this would have on her and her family, so we worked around the problem by getting an EKG done right in the office and getting a chest x-ray. When her EKG and chest x-ray supported our diagnosis, we decided to give her the diuretics as an outpatient and to have her come back for a second office visit in a few days. When she returned, she felt that breathing was much easier, and her physical exam supported the improvement.

Instead of this heart failure exacerbation costing thousands of dollars for an ER visit and hospitalization, this cost only a few pills (furosemide 80mg PO costs about $0.29 per pill, and she was prescribed this once daily in addition to her normal medications) plus an extra primary care doctor visit, which runs about $100.

An Expensive Pain in the Neck

The following anecdote is by Renee Lux, a patient from Connecticut who was among the winners of the 2011 Costs of Care Essay Contest.

One morning this May, I woke up with a stiff neck. I applied hot and cold therapy all day and took an Advil before bed. By the end of that week, I was unable to comfortably move my head and I was feeling numbness down my left arm to my fingertips. I saw my doctor within 24 hours of calling his office. After a brief exam, he was sure of my diagnosis, but he scheduled me for a CT-scan at the hospital the next day, “Just to be certain.”

A day after the CT-scan he diagnosed me with Radiculitus Cervicalgia- inflammation leading to nerve root impingement. I was prescribed a 10-day regimen of prednisone. By the end of my prescription, the pain was gone and my total out of pocket expense was $55 in co-pays. The unintended result of this diagnosis will cost me $2,220 a year in increased health insurance premiums for the foreseeable future.

Stress and anxiety was likely the root cause of my radiculitus. Stress and anxiety brought on by my search for affordable private health insurance. My husband had been out of work for over a year and our COBRA, with the government’s Premium Assistance Rate (ARRA), was about to run out.

I contacted a health insurance broker and explained that I needed an affordable, high-deductible plan for a family of four with no pre-existing conditions. We are all healthy, all average weight and height, non-smokers, none of us are on medication and we have no issues with cholesterol or allergies and no plans for more children.

The broker found us an affordable plan and sent over an application for underwriting which I carefully filled out. Within hours of emailing it back to her I received a frantic phone call. “You said you had no pre-existing conditions!” she bellowed down the line.

She explained that having had a CT-scan and prescription medication within 30-days of my application made me practically uninsurable. She was adamant that the CT-scan alone would trigger an automatic denial. The broker suggested a high-risk plan, which is very expensive. If I couldn’t afford it, I could apply for Connecticut’s High Risk Insurance Pool, but I would have to be un-insured for 6 months in order to qualify.

“High risk?” I thought meekly. I don’t have diabetes, cancer or HIV. I don’t even have high blood pressure. How can I be high risk when my diagnosis was resolved with $5 worth of prescription drugs?

Now I was frantic! I called my doctor. He was incredulous, insisting that my radiculitus was resolved. He offered to write a letter on my behalf. I contacted a friend of a friend, a medical underwriter in another state. All she would say was that my diagnosis within a month of my application throws up red flags for insurance companies.

I took a deep breath and started over with a new broker- we talked over the phone. When I told him about my recent CT-scan I could hear him sucking in his cheeks. There was a long silence.

Finally, he suggested we apply to three insurance companies at once, in the hope that one would accept me. The underwriting process requires me to state if I have ever been declined health insurance. A denial by one company would trigger automatic denials by other insurance companies.

I filled out three applications and agreed to phone interviews with underwriters for two insurance companies.

Eventually, one company offered to cover my family, but denied coverage to me. One company offered us coverage with an exclusion: “This policy does not cover any loss incurred by Renee Lux resulting from any injury to, disease, or disorder of the cervical spinal column, including the vertebrae, intervertebral discs, surrounding ligaments and muscles, treatment or operation therefor and complications therefrom.”

The third and final insurance company approved my coverage with a premium increase to cover my medical condition, “Cervicalgia/Inflammation of the neck.”

Had I known what the repercussions of that doctor visit were, I would have asked my doctor if the CT-scan was absolutely necessary for my diagnosis. Perhaps even the prescription could have been replaced with a higher dose of over the counter anti-inflammatory. The long-term affect of my “pain in the neck” is an additional $189 a month for the foreseeable future.

Teaching Residents about Costs: The Price is Right

It all started while out to dinner with a couple of my fellow Brigham/Massachusetts General Hospital OB/Gyn residents. We were discussing our favorite old TV shows and one fellow resident's love of The Price Is Right with Bob Barker. After talking about the game show, a light bulb went off in my head and I thought, "Why can't we play The Price is Right with hospital charges to our patients?"

With further discussion we realized that none of us knew the hospital charge, or the cost to our patients for routine workups we routinely order in our gynecology clinic. We really had no idea.

After asking around, I realized that I was not alone in my lack of knowledge, or the idea to play The Price is Right with hospital charges. A couple of years prior the Massachusetts General Hospital Internal Medicine residents had played a similar game with the goal to create awareness of the costs associated with routine workups.

There is very little data on how much residents (and attending) physicians know about the costs of what they prescribe, of what changes practice patterns. I had an upcoming conference for the gynecology residents and faculty around the Christmas Holiday and figured that this might be a good venue.

In first thinking about what costs to use, I consulted my esteemed colleague, Neel Shah. He directed me to use hospital charges which are standardized across patients and not specific to the insurance company or patient. I wanted to use Brigham and Women's specific charges, with local comparisons. Because I wanted it to be pertinent to every day care, I decided to use case based scenarios with 3 of my clinic patients, a hybrid with Choose Your Own Adventure.

I started with our gynecology clinic practice manager (after she overheard me discussing where to find these numbers). She had some information on the visits to our gynecology clinic and hospital charges for the technical end for procedures. But, I soon realized that no one really knows how the hospital charge value is arrived upon, or if and how it changes year to year. And while she could tell me the charge for a RN intramuscular injection fee, she told me to contact the pharmacy for the drug charge. After asking around, I resorted to calling the individual labs/departments to find the appropriate costs. People were often willing to tell me as few people even ask. I called the pharmacy, hematology lab, microbiology lab, emergency room billing, hospital billing, the nurse practice manager for the family planning clinic who coordinates with the nurse in charge on labor and delivery, and a separate operating room billing manager. Because OR costs are determined in increments of 15 min, they are provider and case specific.

We choose a recent hysteroscopy that I had done with an attending who does many hysteroscopies on an average case, and she gave the line item hospital charge breakdown. The microbiology manger prefaced her costs with, "Do you have a pencil and are you sitting down, because you will be blown away!"

The ambiguity of the hospital charge was most apparent when discussing abortion. This is one of the few procedures that many insurances do not cover, so the hospital charge is paramount to self pay patients. The hospital based family planning clinic uses charges from 2004 that are currently being debated. It is unclear if there are separate anesthesia charges, or if they are included in the hospital charge. And because the quotes are outdated, it was difficult to tell what the hospital charge in 2011 is. There is also significant variance in performing the same procedure- dilation and evacuation (or curettage) in the hospital based clinic, the main operating room, in a procedure room on labor and delivery, or in an affiliated private outpatient facility. All of these charges affect our counseling and referral of self-pay patients, and the affordability of these procedures.

The game went over very well with participation and wild guessing from attendings and residents alike. I am not sure if and how practice patterns will or should change, but perhaps knowledge of the systemic charges will better inform our counseling of patients, and consideration of their resources. And, I did pause before obtaining an unneeded gonorrhea/ Chlamydia culture the day afterwards with my newfound knowledge...

2011 Essay Contest Finalists

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/2011/12/prweb9050881.htm

Crowd-sourcing medical bills will uncover errors and overcharges

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!

References:
• 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.