A couple days ago I spread out all my medical bills to date to make better sense of them. For each procedure it seems I receive six or so different pieces of paper (with accompanying return envelopes): the initial bill, a notification from Blue Cross Arizona that the claim will be processed by Blue Shield California, a statement of benefits from Blue Shield California, an adjusted bill from the provider, and a secondary bill because by now the whole thing is 60-days past due.
It amounts to a whole lot of paper. Multiply by the 50 or so million people receiving medical care in this country and, well, we can leave it to Harper’s Index to figure it out. After laying it all down on the floor and clumping by month, I went through and organized by procedure and date (something like 35 procedures, 35 dates). Now it’s somewhat graspable. Some of the bills actually itemize individual widgets, sub-contractors, and sub-procedures: it’s a bit like going out for a plate of spaghetti and at the end of the meal receiving an itemized tab with seperate charges for the tomatoes, parmesan, semolina, salt and pepper, soux chef, head chef, dishwasher, and maitre de. Yes, perhaps someone else needs that for their internal accounting, but do I as a consumer? It gives the illusion of information, but is largely unactionable. Am I in a position to dispute the wage or hours worked by the dishwasher? Am I truly able to assess the value of a foley catheter? In the end it all amounts to the same thing: I pay it.
So what, in this case, do we pay? I received my surgery bill last month. My nine hour nap cost $85,868.32. I think I’m pretty much good for the 32 cents part.
That’s just the surgery. I also go in for radiation every morning for a 15 minute treatment. Each 15 minute fraction costs $7000.00. I’m going to have 30 of them. You could say my rent runs about $28,000 an hour. In the end after you add in ancillary costs, the whole radiation circus is going to cost about $300,000 give or take. When all is said and done, for everything, I’m technically probably going to be down for something close to half a mil. Interestingly, most of the wonderful providers involved with my care most likely have no idea what they charge. I’ve asked some, and hey, they just deliver care, what someone pays for their services is a mystery to them. At least in the restaurant, the dishwasher can step out into the dining area on break and take a look at the prices on the menu.
Now it remains to be seen how much of this I owe, and don’t get me wrong, by all means I think it’s worth it. What’s the value in a human life, and my life in particular? And in a world where Wall Street bankers get $20 million for doing their jobs badly, my surgeon and rad onc are probably underpaid. My surgeon took my life in his hands and spent 9 hours doing incredibly painstaking work (with pre and post-op rounds it was probably a 13 hour day for him) in which he managed to remove a bunch of tumors and save my facial nerve to boot. There are only a handful of human beings on the planet who could have adequately done what he did that day. And as for my radiation oncologist, she and her team and their computers are responsible for pointing a big ol’ x-ray gun at my skull every morning and they better have very, very, very steady hands. If they know what they’re doing, they’re worth it.
But it begs the question, what happens if you don’t have health insurance? One unexpected medical issue (and isn’t that the nature of medical issues, that they’re unexpected?) would quickly and effectively ruin most people. I heard a story when I was in Lancaster, PA this summer from a family practice doc who has some Amish and Mennonite as patients. As a rule, Plain Folk pay cash for medical services – they exist outside any governmental or institutional systems – no insurance, no subsidies, no government aid, no nothing – and as a rule, private physicians tend to love ’em. In this one instance, an Amish woman had contracted cancer. She and her husband met with the physician to decide on a course of care. The recommended action was a run of chemotherapy or radiation, but the chances of it doing any good were pretty uncertain. Treatment would cost somewhere between 50 to 70,000 dollars. Husband leaned back in his chair and explained that that was the cost of the new tractor that they had been saving for. The wife and husband discussed that matter, and given the odds of a cure, the age of their children, and the certainty of heaven, they decided that the money would probably be better spent on the tractor.
But that’s not us. Or at least most of us. We want our MTV, and unfortunately few of us are in a position to pay for it. And if you don’t have insurance you are in big, big, big trouble. How in the 21st century, in reputedly the richest country in the world, is this possible?
Now, what about that insurance? At the beginning of the year I needed to have a standard x-ray done. I dropped into Northern Arizona Radiology in Flagstaff, was all set to do the procedure, they asked for my insurance, I slipped them my Government Employee Health Association (GEHA) insurance card, they looked at it, and politely slipped it back. No go, they said. We’re not a preferred provider.
And where was the nearest provider? Prescott, Arizona – 3 1/2 hours from my house. But that’s not all. I needed a pre-approval. If they were to grant it at all, it would take at least a week. And sometimes they didn’t even grant it.
What if I had Blue Cross?, I asked.
You’d be done by now, the receptionist answered.
I left the desk, promptly called my wife and we switched our insurance plan. We had that luxury.
For anybody who is still afraid that health reform is going to jeopardize your freedom of choice, let me be clear on this: GIVE IT UP. You don’t have freedom of choice. Unless you pay out of pocket, you are bounded by the providers in your insurance network. You do not have a choice. In my case, it might have made more sense to have my entire treatment done at the Mayo Clinic in Phoenix. They’re closer to home, and they’re one of the leading tumor/cancer facilities in the country. But guess what? They’re not a preferred provider under my plan. Instead I’m now (gratefully) receiving my care in California. Fortunately they were in network. But what if they weren’t?
But that’s not all. I’m now set to go through my medical bills, figure out my copays and whatever and cut a bunch of checks. Let’s assume I can afford it. But Blue Cross/Blue Shield – and I’m speaking to you now – you have not yet pushed back. And apparently you’re capable of it. Within your cubicles you have a legion of actuaries and hospitalists who are trying to drive down costs by determining what expenses are allowable and not allowable, what fall under my deductible and what do not, and if you wanted, with a single keystroke you could point to some fine-print of your making and put the kibosh on the whole thing. We no payee. Get attorney. End of story.
My friend CatsM? She started her second round of chemo yesterday. Her choice? Get this. You have no more options. Her insurance company’s initial response? We won’t cover it. (Fortunately her doctor went to bat for her on this one).
I love you guys. But why should any of us, including you, have to put up with that?
Lastly (and forgive me if this is sounding interminable), but what of the future? My wife is a federal employee working in a remote location (we drive 120 miles to buy our milk). At some point we will have to move. When we move, we will most likely have to change insurance companies. I have a condition that by definition is recurrent. Odds are that it may be coming back. If it comes back, it will most likely be classified as a pre-existing condition. So in theory, here’s our choice: a) for the next 20 years continue to drive 120 miles to buy our milk, or b) sock away half a million.
And then there’s a third choice. c) the choice of our Amish farmer.
For those who don’t know, my wife is a doctor. She is a highly trained and highly capable physician. She works for the Indian Health Service that, due to the Federal trust obligation, provides more or less free medical care to Native Americans (if any fringe elements want to quibble on this one – give me a call. Please. I’d love to have a sitdown). People love to bitch about IHS. But at least from a doctor’s perspective the system more or less works. My wife can prescribe the needed care based on the medical need and not be second-guessed by second-party payers. She can do her job as a doctor. And the patients pretty much don’t need to worry about the bill. True, they have a hard time attracting doctors (who wants to drive 120 miles to buy groceries?), but it basically works.
But as for our health care? We’re not covered by IHS and so are part of the system that the rest of the country has to contend with. And even for us – get this – even for us, the system is potentially broken. My wife is a damn doctor and even we don’t get a Get Out of Jail For Free card. This summer I talked with family practice docs in Pennsylvania who were up and ready to just quit. They hated their jobs. What did they hate? The insurance companies. They felt that they couldn’t deliver the needed care because they had to constantly fight with 2nd-party billing. The CEO of one of the state Blue Shield franchises has publicly stated on record that the system is broken. A staff member in one of the UCSF billing offices confided to me the same – the system is broken. Every day he has to fight on behalf of patients to make sure that their care is covered. Another friend who makes a living negotiating drug prices with pharmaceuticals contends the same. (Big Pharma’s lobbying tab, by the way, is set to top $150 million dollars this year). Truthfully, most of the people I know, myself included, who work in and around the health care industry feel the system is broken.
For those who are against health care reform: We are the system. And the system is saying: we are broken. The system is broken.