(This post was originally published on the Occupy Healthcare website, December 22, 2011)
About six weeks ago, while in clinic, I developed pain in my
stomach--specifically, in my right upper quadrant, just below the ribs.
I had experienced this a few times before, but this time it seemed more
persistent than usual. Following the rule that physicians make the
worst patients, I kept working through it until my nurse told me I
looked poorly, and made me see my own primary care doc. This led to an
ultrasound that afternoon, a diagnosis of gallstones
with mild acute cholecystitis (inflammation of the gallbladder). I was
in the surgeon's office the next week, and in the OR a week after
that. Fortunately, I had an uncomplicated laparoscopic surgery, and was
home within 24 hours.
Things are fine now. I was back at work
within a few days, and was fortunate to have received prompt and
effective care. However, I realize that my experiences are not
typical. I am a physician, and my primary care physician is one of my
partners: I was seen the same day because I was part of the "family" of
docs with whom I work. The ultrasound was arranged two hours after my
doc saw me. My surgery was scheduled so quickly in part because someone
else's elective procedure was bumped to make room for me. If I had
been an average person calling my primary care doc for belly pain (or
presenting to the ER with the same complaints) I doubt this process
would have been this efficient. I was fortunate to have privilege on my
side: the privilege of being a healthcare professional, in his own
system, knowledgeable about how to make the system work to my advantage.
highlights the fact that our system is not fair. Why should I get
these special considerations? Obviously, the easy answer is that I work
in the health system where I received my care: much of what happened
could be considered a form of professional courtesy where I was extended
opportunities not available to patients not employed by the system.
But at the heart of health care, shouldn't this sort of care be
available to everyone? Why should it be so difficult for an average,
non-medical person to be treated in just this way? Some systems (likely
some of the top systems in the nation) work to make easy and prompt
access available to all comers, but they are the exception to the rule.
need to fix our system to make sure that meaningful, necessary, and
prompt access will be available to all, whenever they need it. The
system needs to be truly patient-centered.
Over the course of the
next few weeks, I began to get my explanation of benefits (EOB) forms
from my insurance. These EOB forms highlight how much the hospital
charged, what my insurance wrote off (or "discounted"), and what I
needed to pay. I am unable to list the costs here due to our system's
insurance contracts, concerns about anti-competitive activities, etc.
This is unfortunate, because they expose another area where our system
is unfair and unbalanced: if you are uninsured, you will be expected to
pay more than if you are insured. This is because insurance
companies negotiate with hospitals on their patients' behalf, and reduce
the costs for which patients are responsible. If you are uninsured,
and if you don't know how to seek financial assistance, you pay the full
(non-discounted cost) of your medical services. That cost is usually
set high enough to ensure your healthcare provider will get the maximum
payment possible from insurers...so the uninsured face the full burden
of this increased cost.
It is not unusual for insurance companies
to negotiate deep discounts for medical services. Discounts of up to
40% are not uncommon. This means that if a hospital charges $1,000 for a
given procedure, the insurance company will only be required to pay
$600 of this--because they have negotiated a discount. This $600 will
then be shared by the insurance company and the patient, who might have a
required co-pay or deductible. If you are uninsured, you do not have
access to this discount and you are responsible for the full $1,000.
The $1,000 price will be set because this is the level the hospital
needs to set in order to recover all available payment. Different
hospitals and healthcare systems will have mechanisms for patient
assistance, but this programs exist at the decision of the system, and
levels of assistance will vary greatly.
So: if I were uninsured, I
would be required to pay more than any insurance company pays...and my
increased liability would be the result of other peoples' insurance
companies negotiating discounts for their patients.
is crazy. Why do we have healthcare systems that charge so much?
Because they feel they need to in order to be able to accommodate
insurance companies' demands for discounted services and still turn a
profit--if systems charged the actual cost of the procedure, then they
would take a "discount" on that amount and end up losing money. Why do
insurance companies expect/demand discounts? Because it helps justify
their existence: if that "discount" were the actual price people were
charged, there might be less need for insurance. Why was my co-pay a
small fraction of the total charges? Because I am fortunate to have
really good insurance coverage.
Presumably people who lack health insurance lack it for a reason.
Most people who are uninsured are not doing so because they like to
live on the edge or save money, but rather because they cannot afford
it. What rationale is there, then, to charge them 40% more than those
who are insured?
If you have ever wondered whether healthcare costs are really that
bad and whether they can bankrupt people, here is your answer. This is
a one-person survey (N=1, to use a medical inside joke), so I can't
claim these costs are representative of others' experiences. But, here
in Richmond, if I was uninsured and did not have enough in savings to
cover the bill, then I would be scrambling to find a way to pay this
sudden medical debt.
It is unfair and unjust that people are
exposed to back-breaking medical costs for illnesses that are beyond
their control. We can argue about the individual responsibility
patients have for diabetes or high blood pressure, though I would suggest it is less than many claim.
But how much individual responsibility is present if someone has
gallstones? Appendicitis? Retinal detachment? Breast cancer? Why
does our system penalize the uninsured if they have the bad luck to
actually get sick?
Our healthcare system is unfair and
unbalanced. Too many lack meaningful access and struggle to afford the
care they can get, while a few have easy access and much lower costs.
We need to fix this broken and dysfunctional system.