Medical billing still broken

Back in June I was doing a major project in the yard and rolled up half the professionally laid astroturf. It’s a major job and weighs a ton… A couple of days later I stepped on the rolled astroturf and an 8-inch turf nail went through my shoe and into my right foot. It went in pretty deep, not just a surface cut.

After cleaning up, covering the hole I realized I needed a tetanus shot. It was already 6:30pm, I called a couple of local urgent care offices and checked their prices. Both said the shot cost $40. I decided to head to the Boulder Community Urgent Care in Superior.

Having filled in my details on a tablet, I was called in and shown to a cubicle. A few minutes later a nurse/doctor practitioner came in, asked a few questions, cleaned the wound and agreed to the shot, having also explained I’d need to take a specific antibiotic that they’d supply the first dose of as my pharmacy would be closed at 7pm. We also agreed that as I was paying cash, an X-Ray wouldn’t be done, but if I had pain in a few days to comeback.

A few minutes later, I was done. I had to checkout and the front desk said that the bill was $192.40 – I was speechless. I asked for a line item/detailed statement and was told they couldn’t provide one then, but I could call the billing dept. later and get one. I paid by credit card and left with a credit card receipt.

BCH Bill for the actual tetanus shotImagine my surprise when a few weeks later when I got the bill from BCH. Yes, that’s right, the bill was for the administration of the tetanus shot. You have to be kidding?

I’d paid $192.40 and that didn’t even include the tetanus shot for $40, discounted by $6 for “cash”. I waited a couple of days and called the BCH Billing dept. I had a productive “how can this be accurate calls” and the woman I spoke with, after a few minutes, agreed to waive the $34 fee.

This though embodies everything that is wrong with the American healthcare business. You can’t get an accurate price up front; they then nickle and dime you for every small part of the process; when you checkout you get a final amount, but you can’t see how that is made up; you pay by credit card and leave, and then weeks later you receive an additional, unexpected bill. That’s if you are lucky.

Opinion | How Much Will Americans Sacrifice for Good Health Care? – The New York Times

Sadly, this New York Times Editorial op-ed is factually wrong in a material way that I had to write a letter. I also ripped into Dan Gorenstein on twitter(1) for linking to the article and “guessing” he didn’t think Americans would tolerate #MedicareForAll.

Here is the text I sent to the Times, who knows if they will publish it. My track record of getting corrections to editorial op-eds published is close to zero. It’s like they don’t want to be wrong.

The editorial board seems both confused, and factually inaccurate when it comes to how insurance works in government funded, single payer healthcare systems. It is common place in such systems to have an option of top-up insurance. I was lucky to have had such insurance when I needed serious surgery in the UK, in 1992. It was employer provided insurance.

One of the constraints in the many government single payer systems is the supply of buildings and doctors to treat a patient “on demand”. Urgent cases are as always seen as soon as they can be. Non-urgent cases, not so much. But then, medically, they are non-urgent. Top-up insurance allows patients to schedule both dates and locations, specialists for non-urgent treatment. The single payer system, pays an agreed amount for the treatment or surgery, much like Americas current insurance based system.

The difference is, that in America today there is massive over supply of both facilities and staff, specialists etc. That over supply is costing every one, both the insured and the uninsured, money for nothing. Yes, it’s great if you can walk into your local Dr’s today and get a referral to a specialist this afternoon for that annoying toe bunion that has bothered you for the past 6-months. Should our healthcare system be based on the costs of carrying that burden? Absolutely not.

While single payer systems are not perfect, nor is the current US Insurance based model. Almost everyone of the people that are involved in charging, finance, billing, negotiating, handling disputes, etc. is overhead. That overhead has to get paid for. So called “death panels” are more common in the US based insurance system than they are in single payer systems. In a single payer system there is no out of network, drug prices are controlled, and there is much more transparency. For everything else there is top-up insurance.

The editorial board overlooking this important fact, does a major dis-service to it’s readers and to Americans who continue to pay too much for healthcare.

Source: Opinion | How Much Will Americans Sacrifice for Good Health Care? – The New York Times

Missing the point of Healthcare costs

We managed to get Health Insurance sorted out for my wife and daughter, without falling into the trap of me getting covered by an ACA policy, which would put me in jeopardy of violating the “public charge” agreement I accepted when applying for my green card. I’m self-insuring for another year aka uninsurance.

Today I took my daughter to the dentist, she needed two baby teeth pulled to make way for her adult teeth. The insurance didn’t verify when they put it in. So I paid by card. In a subsequent phone call we went through the process of how to claim the money back. The process involves mailing in an invoice, the insurer authorising it, contacting the dentist and having them re-submit for insurance payments, and then finally refunding us our payments.

Of course, I won’t pay for any of this back and forward. Insurance does. Insurance will pay the broker and admin who finally were able to spend a full hour helping us get the forms submitted without putting me in legal jeopardy.

The paediatric dentist will absorb the cost of trying to get the bill paid through insurance, then after discounting their charges for “cash”, taking a hit for payment by card, and then there is all the additional admin that the dentist and the insurer will have to put in. None of that is free, it’s all rolled into the cost of insurance. Repeat that thousands of times per day over a population of 300+ million…

Before this episode is finished, it will have cost more for the admin than the dental treatment. That’s madness. That’s just one small reason why we pay so much for medical insurance, and it’s invisible.

An Apple a day keeps the Doctor Employed.

apple drCNBC has an interesting article about the number, and quality of Doctors they employ.  I’ve no idea what’s going on an Apple, for a number of reasons, I’ve never bought a single product of theirs.

However, given their deep pockets and ability to play a strategically long-game, I for one would be surprised if this isn’t significantly more than just about the watch and apps that can diagnose conditions based on data in collects.

Here are my thoughts, in the form tweets to @charlesarthur original tweet and link to his daily Startup link list overflow.

 

Maternity medical crisis

As we approach this year’s open enrollment period for health insurance, I continue to be shocked and disappointed about almost everything I learn about the US Healthcare system. Before I return to notes about my own experiences and my own health, maternity care is another healthcare topic that doesn’t often get discussed, as the average American prepares to pay more than $10,348, per person, per year on healthcare.

While many argue about the definition of single payer, and if it would lead to socialism (and what that is?), the inefficiency, mistakes, cost and just outright expense of what should be routine treatment, continues to make me despair.

America has healthcare snobs, millions of them, they just don’t realize that while they might have great access to medical facilities and Doctors, that doesn’t mean it’s always good, or that the system acts in their best interest. However, any suggested change is met with claims of death panels, socialism and more. Oft heard is also they ‘don’t want the Government in the healthcare.’

Even I was left speechless as I watched a recent CBS Sunday Morning segment on maternal healthcare. Among the points made were:

  • U.S. “most dangerous” place to give birth in developed world
  • The United States is ranked 46th when it comes to maternal mortality. That’s behind countries like Saudi Arabia and Kazakhstan.
  • “Sixty percent of the deaths in the United States are preventable,”
  • At least two women are dying every day

And it’s not about access to healthcare; it’s not about the poor without insurance; yes, there is a racial element, but it’s not what you’d think. Here is the entire segment, well worth watching before you enroll this year.

| Edit: The embedded video doesn’t apparently load in some browsers, so here is a direct link to the CBS This Morning web page. https://www.cbsnews.com/news/maternal-mortality-an-american-crisis/

Can it be true that women giving birth in America are more at risk than women in dozens of other countries?

“Profiteering” in prescription drugs

The New York Times has an interesting piece on the price of drugs, of which Pharmacy Benefit Managers are only part of the story. Add to this the general secrecracy over prices and Pharmacy benefits and drug list (aka the formulary) which are their negotiated discount drugs, brand or generic.

This has been my experience, even without insurance, it’s almost impossible to find out how much specific drugs are going to cost in advance; if there are cheaper generics; and if there is a better price.

Glass full, not half empty!
Drugs R-US

I took an alternative route and did a deal with the devil for my most expensive drug. Despite having supplied the drug manufacturer with more financial information than I did to get a mortgage, they still declined to help financially, unless and until I applied for AND was declined for Medicaid.

I most probably would be eligible for (full scope) Medicaid, since I’ve already surpassed the 5-years/40-quarters requirement. That said, I’m really not comfortable in applying for any government assistance(despite assertions like this unofficial website) until I become a full US Citizen.

Faced with a circa $300 per month drug cost, I took an alternative route and was able to secure the best part of a years’ supply. Also, to get to this point, I’d spent probably 50+ hours trying to find alternative prices and supplies.

Like many other things, this is another example of the disgraceful profiteering in the US Medical for-profit business.

On the remainder of my medical billing, I’m about to give-up, the system has worn me to down, I just can’t waste any time or energy on it. In my last communication, I laid out specifically, in detail where the billing didn’t agree with what they’d told me the cost would be. Their answer:

Our financial aid has been applied and your balance is correct. If you have any other questions, feel free to contact our customer service team.

Which takes between 30-60 minutes per call since you have to go through multiple layers of call center and no one has any real authority to change anything which means they have to appeal to a “supervisor” and they never return calls. It’s time to pay them all off before they go into collection and hurt my credit rating.

Medical Billing update

After spending another hour yesterday making calls to try to come to a conclusion over the 2x appointments and treatment I had for my leg wound back in August and early September. I’ve been applying the lessons learned, experience I’ve had resolving my billing for my heart attack, which i close to, but not yet finally resolved. Here are some tweets I sent after getting off the phone yesterday.

Doctors and Money

The NHS is funded(or should be) to take care of everyone to a level of minimum care. No one(in practice) should have to pay for any medical care.

One question that comes up regularly when discussing how to fix the healthcare system in the USA, is Doctors and Money. While Doctors are far from the only important people in a healthcare service, they are possibly the most visibly important.

It is often asked, or asserted, that if you had a single-payer healthcare system where Doctors were possibly salaried this would act as a disincentive, and over time you’d lose the best doctors to purely private practice. This belies the fact that experienced doctors in the British NHS can make additional money in private practise.

It also completely ignores the fact that while the NHS is a meets minimum, free at the source of treatment health service, there is a thriving private, and private insurance marketplace.

The NHS is funded(or should be) to take care of everyone to a level of minimum care. No one(in practice) should have to pay for any medical care.

However, these days the cost of drugs, the number of highly complex surgical procedures that are “standard” has grown beyond the normal funding of the NHS from say 20-years ago. Cancer care and the drugs for it now consume huge amounts of money, as does the treatment for obesity and the treatment of it, including heart disease.

If you are in a car crash, some form of violent attack, or other urgent care need, the NHS will supply an ambulance, emergency care, surgery, drugs, Dr’s, everything and you’ll never see anything related to billing or cost. Same for almost any minor health care problems, even many elective surgeries, and pregnancy, cancer care, pretty much any medical need.

Elective surgery does tend to get backed up, there are often long waits to see a specialist, as well as to get surgery. This depends though on the problem, the area of the country, and the time of year.

This time of the year the NHS is always stretched to and beyond its limit. It’s damp in the UK, older people tend to have been life long smokers and are very susceptible to respiratory illness. Both my parents died this way after a few weeks of gradually declining health as they were unable to recover from pneumonia. My Dads complicated by heart disease; my Mum a 7-year lung cancer survivor.

Both received 100% free NHS service, they were not rushed or hurried to move out of their hospital beds. The nursing and medical attention was top class. In fact, I’d go as far as to say  much better than here in the USA because there was never a discussion, question or insinuation that insurance might not cover something.

For those that a “meets minimum”, free healthcare service won’t do, you can always pay. Many companies offer private “top-up” insurance, which provides priority appointments, private hospital beds etc. And you can always elect to pay for the treatment you need need.

luton-news-sept-21st-1978I had two major hospital admissions, one on the NHS for a tib/fib fracture in 1978; the 2nd some 16-years later for corrective surgery. The 2nd I was working for IBM with top-up insurance. I saw the same specialist who’d saved my leg 16-years earlier. If I’d wanted to see him on the NHS, there was an 4-week wait; I saw him the next week at a local private hospital.

He recommended corrective surgery. On the NHS he would have done it in 4-6 weeks, depending on lots of things. I was able to schedule a specific day for 10-weeks out that better suited IBM’s schedule, private hospital, private staff, same consultant.

Fast forward to 2013. I’ve done over 100 triathlons and running races, including 6-Ironman races. Despite an initial prognosis in 1979 that I’d never run again. My knees are not so good. I wanted to see the same consultant, he is no longer practicing, wished me luck. I was recommended to the British Olympic Association’s Orthopedic Consultant. Chances of seeing him on the NHS, zero to very little.

I scheduled an appointment with him at Private hospital, flew to the UK, and he came in to see me especially. We spent the whole hour together, what I’d paid 450 UKP for. We discussed options, did measurements, x-rays, looked at different types of replacement knees etc.

He said that when I was ready for surgery to let him know, he would schedule me on his NHS roster and I could fly back. When discussing the same surgery here in the USA, he told me not to bother.

His experience had been that in the USA even dedicated specialist consultants didn’t have nearly the experience as NHS Specialist. In the USA they spend too much time consulting with patients and negotiating over billing. Patients in general take 3x as long to consult with in America because the options, cost and insurance options, and choices are so daunting and often when a preference is stated it has to be negotiated with insurance, co-pays, deductibles etc. all have to be understood by the Doctor and patient. The alternative is you get the Doctor, but little or no choice in replacement technology.

He has 2x 6-hour surgery days per week, they do 6-8 knee replacements per day; he spends 1-day NHS consulting, and 1-day private consulting and has 1-day open for Private surgery or additional consulting.. If he wants he can do private surgeries on Saturdays, vacation days or early mornings before NHS work. Average cost for NHS Surgery $0.

A US Specialist, according to him, does 6-10 operations per month, and my US research was cost around $30,000. In terms of knee replacements, the UK has much better insight, and much less medical device and insurance company influence on the type of replacement, they base their choices on OUTCOMES.

I’ll return to the discussion on healthcare systems shortly, but suffice to say, I’ll be going back to the UK when my time finally comes.

Healthcare perspectives

Although I’m tempted to write a blog post on the current debacle around the Texas legislature’s attempt to remove Women’s choice on abortion, by legislating abortion clinics pretty much out of existence in Texas. I won’t since thats not really healthcare, it’s basic human rights, freedom of choice and freedom of the individual.

I’m heading, this time next week, to my last full distance aka Ironman Triathlon. It’s my last since my right knee is pretty much wrecked, some 36-years after smashing my leg to bits in a motorcycle accident, and some 40-years after having the meniscus removed following a number of soccer injuries. My left knee also shows signs of excessive wear and tear. In 2009 I was referred to Dr Doug Elenz who after looking at x-rays said “a picture is worth a thousand words, I only need six – I don’t know how you run?”. He also said “your right knee needs replacing now, and your left knee soon”. We laughed and joked and I have not seen him since.

So I’ve been considering my options for when I get back. Knee replacement, lot’s of new alternative therapies. A couple of interesting things prompted this blog post though which just show how different things are here in the USA. I checked with a couple of medical insurers websites on type types of treatments available. Here is an example on the Aetna website, it would be nearly impossible to meet these requirements since one or more of the conditions would need to be present in order to make the treatment necessary.

I checked with a friend back in the UK, and yes, provided a Dr referred me to a consultant specialist, and the specialist scheduled the treatment, this would be available free of charge. There may be a waiting list for a hospital bed and surgery.

If I worked for a large multinational, as I did when I was in the UK, I had company provided top-up insurance. Rather than being full health insurance American style, what this did was provide for the things that the UK public healthcare system didn’t. I wouldn’t have had to wait, I would have had a private room. All mostly still at no cost, that’s right, no co-pays none of the other nonsense charges that a US insurance policy mandates.

It wouldn’t be totally free, since the government considered the private insurance a taxable benefit, the value of the insurance was added to my annual income declared by the company to the government tax authorities. So, basic healthcare for everyone, for free. Improved access for those that can afford it or have additional insurance. Both of these come without the panels, expense and charging bureaucracy that are weighing down the US system, the cost and expense mostly actually goes on Heathcare.

The real reason for writing though was an email from a neighbor. He was trying to raise money for his sons’ knee surgery. I’m just left speechless really that average American families have to resort to this sort of thing. Where is the dignity, the respect, the care in a society that allows this to happen?

Everytime I think I understand the American psyche, the societal norms’ something like this comes up and I have to take a step back and accept I just don’t get it.

Some men see things as they are and say, why; I dream things that never were and say, why not. – More at: http://www.youtube.com/watch?v=dvo-7YrMoK0

Senator Edward M. Kennedy quoted these words of Robert Kennedys in his eulogy for his brother in 1968.The New York Times, June 9, 1968, p. 56

Guantánamo Adds Medical Staff Amid Hunger Strike – NYTimes.com

This has been prime news in Europe today and yesterday, that 2/3 of the detainees are now on Hunger Strike, and more than 40 are being force fed. I’m sure this also more than news in many other countries. [BBC; Süddeutsche Zeitung (Germany)]

Whatever you think about the people being held, “terrorists that should rot in hell”, “that should be locked up forever” or “deserve their day in court”, the damage this is doing to the US reputation overseas is immeasurable, and it will be held against us.  Time to end this. The President promised 4-years ago to shutdown Guantanamo,  now is the time for action. While “waterboarding” may not qualify as “cruel and unusual punishment: under the US Constitution, Force Feeding is most definitely clearly a violation of international law.

Interestingly, while this is news outside the US, apart from blog entries, I hadn’t seen or heard it covered on US “News” 24hr or otherwise, TV or Radio, unless you did?

Guantánamo Adds Medical Staff Amid Hunger Strike – NYTimes.com.