Thursday, December 2, 2010

Cost-awareness anecdote: Three Ultrasounds (contest finalist)

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

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

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

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

Three ultrasound bills from this pregnancy.

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

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

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

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

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

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

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

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

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


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

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

    1. Underlying this story is the belief that the medical treatment sought is necessary or beneficial. That is often not the case.

      Some folks are aware of the need to defend themselves against iatrogenesis. Few people are aware of the need to defend themselves against financial harm caused by unnecessary and expensive medical treatment.

  3. I have problems with this essay:

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

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

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

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

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

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

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

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

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

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

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

  9. Yes, that's it! Saddle poor patients with $5000 bills instead of $1400 bills they can't afford.

    Actually, the 4D spam is totally appropriate here as an illustration of the underlying problem: unbridled greed by organized medicine.

  10. You're not getting it, are you?
    Pushing this here is discrediting your own selves.
    Thank you for making our point for us.

  11. الحشرات كائنات صغيرة مزعجة للغاية كما أنها تعمل على انتشار الأمراض بشكل سريع لذلك فعلينا أن نقوم بمواجهتها عن طريق شركة مكافحة حشرات بالاحساء التي تعمل على مواجهة جميع أنواع الحشرات

  12. تعتمد شركة ابادة حشرات على مجموعة من الكفاءات البشرية التي لها الكثير من المهارات و الخبرات في كيفية القضاء على الحشرات بجميع أنواعها و في أسرع وقت ممكن


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    التنظيفات المشهود لها عالميا
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