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.

Federal Debt, Student Loans, and the Physician Workforce

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.

References
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.