Your Hospital Bill is How Much?
I’d like to tell you this is an unusual occurrence but this sorry tale is so common that I’ve come to expect these stories to emerge on a regular basis. This one striking just a little bit closer to home when a friend reached out for help. They were having some challenges with a healthcare bill that they thought was unfair and wondered if there was anything that could be done. Always willing and increasingly finding myself awash with frustration with a healthcare system that claims to be a leader but the day to day experiences seem to fall far short of any kind of leadership that others would follow.
An example of internal fixation with pin and plates
This person had broken their ankle – and the resulting fracture needed surgical repair with the insertion of supporting plates and screws to hold the bones together while they heal. Something we call “Internal Fixation”. This is the most common injury treated by Orthopedic surgeons and the treatment and outcomes well documented and all very good. A 2009 study of a discharge database they showed very low mortality (1.04% of patients) and low instances of complications: Pulmonary embolism (0.34%), wound infection (1.44%), amputation (0.16%), and the requirement for revision open reduction and internal fixation (0.82%). (Complication rates following open reduction and internal fixation of ankle fractures).
All good news for our patient who underwent surgery and was discharged home. That was right up until they developed a Staph infection that required them to be re-admitted for removal of the infection and intravenous antibiotics administered through “Peripherally Inserted Central Catheter” or PICC line for short.
You can see a picture of this from CHOP here
Courtesy CHOP
Courtesy Bloomberg
Roll forward a few weeks and the patient is recovering, right up until they get the bill form the hospital in the mail. The patient responsibility – $130,000. No that’s not a typo there is no extra zero on there, it was one hundred and thirty thousand dollars. Roughly the same cost for buying a small Archer single-engine plane!
Who’s to Blame
In a recent podcast, I talked with Chadi Nabhan, MD, MBA, FACP about his recent paper on medical error memes and the viral nature of news grabbing headlines that are based on erroneous data. I also spent some time with Maria Panagioti, Ph.D. talking about preventing “un-preventable errors”. Both highlighted the issue of classification of errors and the important difference of anticipated errors vs unanticipated errors. In this case, given the statistics, I think any reasonable person would expect to receive the care without any expectation of suffering any of the complications all of which occur at a rate below 2% or less than 2 people out of a 100 who have the surgery would get a complication. So while post-operative wound infection is a known risk it is not an anticipated outcome.
So the question in my mind is should a patient who undergoes care be expected to pay for failures and complications that while known should not be expected? If you put your car into the garage for a service and while they are changing the oil the lift malfunctions and damages your tire would you expect to pay for the repair of the tire?
The current “standard” is that complications are the payor responsibility as this study that looked at Medicare patients in 4 common operation groups who showed higher costs from more complications. But in this instance since its Medicare this is the insurer paying these extra costs, in the case the US government and the Medicare program, and as a large payor they have introduced many measures and triggers that preclude or reduce payments for care that falls outside the expected outcomes and attracts a higher complication rate than you would expect. But for many individuals saddled with the current coverage “du jour” – High Deductible plans these costs transfer to the individual. There are a few places working to address this such as Geisinger that offers its money-back guarantee and gets positive reviews and happy patients.
Insurance that’s Not Insurance
I did not have access to the insurance details in this case but the information I received suggested this was a high deductible plan and there apparently was no out-of-pocket maximum meaning everything beyond the small percentage the insurance company paid (and I don’t know if they are paying anything) is the individuals’ responsibility.
There are some obvious concerns that a plan such as this even exists given the huge financial exposure for a relatively simple treatment for a minor accident and fracture. With the polarized views on healthcare, insurance coverage and the inability for any discussion to take place without it quickly descending into a personal high-intensity fight it is hard to make any comments. On the one hand, plans like this exist because people are trying to scrape by. The approved plans that would not allow for this prove to be very expensive running to thousands of dollars a month (after tax if you are self-employed or not part of a corporate plan making them even more expensive and relatively poor coverage). When you have a rent/mortgage payments, food bills, transportation and other financial demands paying a high amount of your income for something you may not (likely not if you are young) need can prove to be a very difficult decision to make.
So without addressing the cost of coverage the push back will continue and for some it even becomes cheaper to take the financial fine for not having coverage each year than to pay the high cost of minimum coverage that is available to you. Am I the only one that finds this notion that the system pushes rational humans who certainly don’t want to lack medical coverage to pay a fine to the government at tax time rather than pay for medical insurance.
There’s plenty of push back on Universal Coverage (Norway has Universal coverage) and even Single Payer systems (The UK has a single-payer system in the NHS, the payer being the government). But we have a single-payer system here in the US as well – Medicare and the Veterans are both single payor.
It’s superficial nonsense to suggest that Medicare for all will solve our current healthcare crisis and IMHO just political windbags trying to score points for themselves in the political gridlock they call government. I’m not arguing for or against the concept simply stating this won’t solve our problems and healthcare is a highly complex, interconnected system and sound bites no matter how clever will not fix our system. It will take thoughtful intelligent incremental steps that take account of the existing system and massive armies of special interest and the existing flow of money. Pull-on one thread and another will unravel. That does not make it unsolvable but it does require working together, civil discussion and disagreement and ultimately compromise on all sides with a guiding star of improving things for the people/patients.
My sense is the solution will come from private-public partnerships in the states and in the industry with unique solutions tested in local markets and states that can prove to work and be adopted and rolled out more widely as people look and see success.
What’s a Patient to Do
Back to our patient, who not only endured an unpleasant and potentially debilitating complication and of infection and requiring additional time in the hospital for treatment but then got spanked over the head with a bill that must have had to be re-read multiple times before they could believe it was real. That stress and adrenaline coursing through the veins are not doing your overall health, blood pressure and wellness any good and likely decreases any positive improvements being made to the ankle as the patient tried to reagin mobility and utility from the joint.
I polled some resources including the active Facebook group “Paying Till it Hurts” that can make a grown man cry if you spend any time reading the sorry takes and miserable experiences many have with the healthcare system. The group grew out of the New York Times series of the same name and subsequent book by Elisabeth Rosenthal (@RosenthalHealth) who I had the fortune of interviewing a while back
Dr. Rosenthal is a true trailblazer in exposing these stories and fighting to right these wrongs. There were some good suggestions that included offering to pay the Medicare Rate for this procedure, which is set by the government and widely accepted by facilities for Medicare patients.
In fact in this study from 2017 Economic Burden of Inpatient Admission of Ankle Fractures, the author suggested that much of the inpatient treatment took place as an inpatient and would serve patients better to be delivered as an outpatient offering the same outcomes and lower costs. In this case, the average reimbursement for inpatient treatment was $12,920 for medicare and $18,613 for private insurance. Both numbers a far cry from the one hundred and thirty thousand dollar bill this patient received
Whatever the outcome perhaps the learning point for others is – if you think you are dodging these problems in healthcare, think again. They strike, out of the blue and with a vicious nature that will sap your strength and energy. This is all of our problems and it deserves open, honest dialog and debate and a solution for everyone.
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