In the spring of 2005, the sinus infection returned. I awoke severely congested with a pounding forehead and pain around my eyes that grew worse when I bent to tie my shoes. The feeling was familiar. Two years earlier, I had similar symptoms, but was uninsured and endured a miserable week with nothing but over-the-counter medication. Now they were back.
Fortunately, when I started graduate school, my father insisted that I have health insurance. As a healthy 24 year old, I didn’t see the need, but he agreed to foot the bill for a high-deductible insurance policy to cover me in the event of catastrophic illness. Except for four physician office visits subject only to a $35 co-payment, my policy offered no benefits until I spent $3,000 out of my own pocket. With my sinuses throbbing, I knew I needed to use one of those visits. Overwhelmed by the list of “in-network” providers on the insurer’s website, I picked an internist based on convenience—his practice was located in a medical complex near my home.
Arriving for my appointment, I checked in and presented my insurance card to the receptionist. “Your visit today will be $35,” said the woman behind the desk. I was relieved to hear that my coverage was working as promised. A nurse ushered me to an exam room, where the physician promptly entered, half-heartedly listened to my complaint, and confidently asserted that I did not have a sinus infection because I had no fever. I wanted to say “Really? Mind handing me a tissue so that I can show you what’s been coming out of my head?” but resisted the urge. Instead, I clarified that fever or no, I didn’t feel well, and believed my sinuses were the culprit. At this, the internist lost patience. He ordered some lab work and a sinus CT scan to rule out infection, and said that I could have everything done downstairs.
Despite my $35 office visit, I knew my insurance wouldn’t cover anything else until I met my deductible, so I needed to find out the cost of the CT scan. Doing so was much more difficult than I expected. Admissions didn’t know the cost, so they called the imaging department. Imaging had no idea, and threw it back to admissions where, after much searching, a big black binder full of prices was located in a cabinet, alongside packets of coffee creamer, some paper clips, and a couple of dried up ink pens. The sinus CT would cost roughly $900, which I could not afford. I headed instead to the lab to get my blood drawn, not knowing that I was about to make a costly mistake.
I worked as a phlebotomist during college, so I knew that lab tests were expensive, but that most insurers negotiated discounted rates that were only a fraction of the sticker price. Besides, the lab work was routine—a comprehensive metabolic panel and complete blood count—so I didn’t think to ask how much it would cost. My mistake was assuming that the lab was in-network, because the in-network internist I had just seen worked in the same building and referred me to the lab.
A month later, the bad news came in the mail. The lab was out-of-network, and I owed $478. While this wasn’t the five-figure medical bill many families face, everything is relative. For me, a graduate student living almost entirely on borrowed money, the bill changed how I bought groceries, socialized with friends, and commuted to school. For six months, I fought to scrape together enough money to make monthly payments. The experience, while costly, taught me a lot about our fragmented health care system, how little patients or providers know about the real cost of health care, and how hard it is for patients to make price-based decisions when the system isn’t designed with that in mind.
I had learned my lesson. Later, when a dermatologist put me on medication requiring monthly blood tests, I took out the yellow pages, looked up laboratories, and dialed the phone. “I’m uninsured,” I said (not far from the truth given my coverage) “and I need to have a lipid panel and a liver function test. How much will this cost?” Some labs knew, and some labs didn’t, and the answers varied widely. Needless to say, I chose the least expensive option. Making the decision was easy, getting the information on which to base the decision was—and is—the real challenge.
On Labor Day Costs of Care, a Boston-based nonprofit, offerred $1000 prizes for the best anecdotes from doctors and patients that illustrate the importance of cost-awareness in medicine. Two months later we received 115 submissions from all over the country – New York to California, Texas to North Dakota, Alaska to Oklahoma. We feel these stories are poignant because they put a face on some of the known shortcomings of our system, but also because they unveil how commonplace and pervasive these types of stories are. To learn more about the contest and read more of our stories please visit www.CostsOfCare.org (Twitter: @CostsOfCare).
Health care is certainly expensive, both for the insured and uninsured. However, I cant believe this story. In my experience, the insured have much lower pricing. The lower price is usually given after the insurance company calls to clarify charges. I expected to read that the charges would total about 5 or 10 dollars less than the annual deductible, which is what ive seen on EVERY 1000 to 50000 dollar hospital bill.
The $478 dollar bill helps to pay the tests for the other patients with the in-network insurance company (those patients may only be charged 50 cents for the test). Furthermore, a lab test in an internist’s office is not under the same scrutiny as a lab test performed in the large hospital/reference laboratory. I am not saying it is right, just that it is. There is no free market in healthcare because if this was a free market, then anyone can prescribe medication, sales taxes would be added to the cost of a visit like any services, and anyone can put a sign up and say they provide healthcare whether or not they are doctor. Oh, wait, I forgot physician assistants and nurse practitioners provide healthcare. We need Health Care Reform, not Health Insurance Reform.
Interesting Blog, even though this was not what i was looking for (I am in search of clinics like this one> http://www.ccsviclinic.ca/ )… I certainly plan on visiting again! By the way, if anyone knows of a good clinic that does CCSVI Screenings? BTW..thanks a lot and i will bookmark your article: Blood Test Surprise…
Time can change most of things ,but not all of things.
I feel your pain Brad. In undergrad and then grad school I tore both ACLs but didn’t have coverage so just “walked it off.” Nowadays, I would probably have better options, as would you and your Cost of Care folks. Let me elaborate.
I generally disapprove of plugs in posts so I won’t put in a link to my site, but clearly not enough people know about our new and useful service for anyone in Brad’s situation (although Health 2.0 has been very supportive – thanks Matt, Indu, Lizzie,…)
In short, if anyone is in Brad’s situation, we have a solution.
Anyone with an email address can go to our site (FairCareMD) and get a fair price for the care you need. We have lab tests in every zip code, lots of doctors, and an amazing patient advocate team that not only knows the fair prices for everything, they can get them for you pretty quick. We have also taken a page from Health 2.0 and enabled user generated healthcare because you can actually request the services you want or need or modify the listed request.
Welcome to the true Open Healthcare Network.
As for folks wanting care for free… well that wouldn’t be very fair to the doctor either. You see, we aren’t just trying to be fair for Patients, but also the Providers who are often paid unfairly by some plans that think $17.50 is a fair price for their time. In many cases we believe this directly leads to the sub-standard interaction Brad had with his ENT.
Thanks Health 2.0 for your support of our movement which helps folks like Brad every day and thank you Brad for sharing your story. We invite all to use our system or comment on it here. Feel free to join the movement too – because this YOUR care we are talking about. Whether you are getting it or giving it, you want it to be the best there is at a fair fee.
p.s. You can get a lipid panel for about $50 on FairCareMD or the full panel that includes the liver tests for about $100. A top rated ENT who listens (and is a heck of a nice guy) for about $125, a CT of the head and neck for about $175. Once you had a diagnosis and treatment plan, if you didn’t like the price the provider set you could go back to the market and get three prices for the recommended procedure. Remember to get a copy of all your records first though!
* Note, in homage to any payers in the audience: all prices in this post are estimates and do not represent any provider’s or physician’s UCR or “regular” fee.
Face it Nate–people like Gary L. want their health care for free. They do not want to take any personal responsiblity for any part of their lives when it comes to health care. They will always want to blame someone else. They will never look in the mirror and they can do absolutely nothing for themselves. They can’t even get their lazy butts to the doctors office. A bunch of big babies.
“How ludicrest it is that, Health Facilities and Insurance can secretly set pricing and still not be up front with their members.”
Ya you go Gary how dare those sneaky insurance companies set secert pricing then try to cover it up by printing it on every EOB and labeling it Provider discount with a note that the member isn’t responsible? How are people like Gary suppose to know discounted amount really means evil secert negiotated price?
Welcome to the maze of Health Care ambushes.Can’t you feel the knife sliding between your shoulder Blades. In the real world ;such shifty,underhanded and unethical behaviors would land most business’s in bankruptcy and prison.
How ludicrest it is that, Health Facilities and Insurance can secretly set pricing and still not be up front with their members. Oh don’t you love those suprises! The consumer is being scammed by insurers and providers. Paying little to nothing and taking entitlement payments for shafting customers!
Health Insurance has played on your fears and made fools out of all of us. Ask yourselves why providers and insurers cannot provide any degree of transparency. Constantly surprising us with excessive costs and hidden charges. They unapoligetically providing patients with medical Errors and Staph Infections. Doctors and Hospitals Save Lives and they often take lives as well!
It would be a change if they would try to justify their prices versus actual costs. It will be like the run away pentagon vendor toilet seat at $100.00 when it can be bought for $15.00. I gather that all the prices health care charges,would exceed defense spending.
“My favorite one of these is when you’re having surgery”
You meant emergency surgery right, not the more common schedule surgery that accounts for 80% of all surgeries. Being that scheduled surgeries are well scheduled and you have plenty of time, weeks even months, to make the phone calls to confirm they are in network your rant really wouldn’t apply. Then again most emergency surgeries fall under emergency benefits, at least they keep the naming simple, where you aren’t penalized for not taking action you couldn’t possibly take. It almost, in a way, appears they designed the system to be fair to all but those that are too lazy or stupid to put a little effort into it.
While those libertarians can be annoying they are nothing compared to the ignorant self righteous perpetual victims that go on blogs complaining about everything not being handed to them in life. Why is it the same person that can schedule a weeklong vacation and make sure their flights, hotel stays, transportation, food and entertainment all align perfectly can’t be expected to schedule a surgery with 3-4 providers?
Rbar for $5-10 a month anyone could buy access to a couple of the largest PPOs in the country and have guaranteed discounts to a million providers. At rates below the 1.5 to 2 times you mentioned. The product/service is already in place, people make the conscious decision to buy an extra cup of coffee or go out to dinner one night a month more than cry like babies when their decision bites them in the ass. Why should we feel any sympathy for someone stuck with a $1000 in medical bills because they refused to spend $60 a year?
“The insurance carrier will punish you financially for going out of network to a doctor who is better. “
It never stops with you bleeding hearts. No Dr. Stenes the insurance company does not punish you, you punish yourself by choosing to see the doctor you feel is better. Network status and network or out of network benefits have nothing to do with your perceived quality, it is merely a financial arrangement to control cost. Further, to be blunt, it is stupid to always see the “highest quality” doctor. In Cleveland a 99213 reimburses $50ish for just about any decent and good provider. Cleveland Clinic bills it at $180 and some large name insurance companies allow them $150ish. With your advance degrees can you explain the logic in paying $100 more to have a flu diagnosed?
“and what most people do in metro areas is to join an HMO go to one group and have them ‘manage’ for them.” Gary, what do you think the word most means? I think it is common to imply a majority, more then do not. HMO penetration peaked around 25%. You can’t find a metro area anywhere in the US with 50% HMO market share. And that is the broader classification based on license and counts the PPO and POS plans that operate under an HMO license but don’t practice the way you describe.
“There is almost no way for a patient to negotiate this system.”
Except the tens of thousands that do every day. Its only hard if you go into it expecting someone else to do all the work for you.
In addition to sites like Healthcare Blue Book, or your insurers site, ask a friend or family member with insurance. This info is not hard to find if you put a little work into it. You can spend more time trying to find the best price on an ipad then figuring out what to pay a provider.
“theysend the checks to the patients, to punish me for refusing to “join” the network, aka conspiracy.” Dr. Melanie take off the tin foil hat and ponder might the reson they send the check to the member have anything to do with assignment of benefits and the legal issues related to who they have a policy with? In one paragraph you brag about your independence and how you stand up to the idiot insurance companies then wonder why they won’t mail you the payment? LOL glass houses doctor. If they sell John Public a policy and thus have a contract with Mr. Public and they have no agreements or working relationship with you how is it you expect them to send you the benefits of Mr. Public’s policy?
“The myth of the “informed consumer” shopping for health care and driving competition and lower prices is ridiculous when there is no transparency at all.” Toni if a consumer goes to a car dealer and refuses to check kbb.com before hand and thusly overpays is it the fault of the system or the consumer. The information is available, when people get sick of overpaying they will become informed consumers, until then they will be poorer consumers.
If you need a comprehensive health checkup or any expensive medical work done, I would suggest trying a hospital in another country. I had a very comprehensive check-up in Bumrungrad hospital in Bangkok for around $1500. That included about 6 lots of blood tests, chest x-ray, bone density check, urine test and lost more, incuding seeing doctor and nutritionist. Basic blood tests in Bangkok are about $5-10. Even the most expensive ones are under $50. I’m from the UK and I have to say that the quality of the facilities, the quality of the doctors and the quality of teh hospitals are much, much higher than I have ever experienced in the UK. The UK health service seems 3rd world compared to the top hospitals in Thailand. So you get better service at a small fraction of the cost. FOr the health check-up I had you could fly from UK, spend 2 weeks in a top hotel, get your tests and still pay less than the UK.
Why waste your money in USA, UK, etc, when there are far superior and far cheaper services elsewhere in the world?
Your story is far too common. As an Internal Medicine Doctor, I hear stories like this every day from patients and I try hard to anticipate what will or will not be covered for them. If you survey 10 physicians and ask what a sinus CT or a metabolic panel will cost, I bet none will be close to correct. I can think of no other “industry” where this would occur.
The myth of the “informed consumer” shopping for health care and driving competition and lower prices is ridiculous when there is no transparency at all.
What an unfortunate situation. It appears that those serving you failed you in several ways.
First, unless there is more to the story than presented, I simply can’t justify your physician’s approach to your symptoms. One could argue for or against the merit of a CT scan (most would probably vote for a trial of antibiotics first), but why the labwork? Sinus infection, allergies, migraine, brain tumor, whatever the cause, a CBC and (especially) a CMET are minimally helpful in the workup of head pain.
Your story regrettably illustrates that one should think twice before spending more on the care plan of a medical provider who seems either uncomfortably uncertain or frustrated by the situation.
Next, the lab could have, and should have, informed you that they were not “in network.” Most people would not think of asking in this situation.
Lastly, $478 for a CBC, CMET and venipuncture is astounding. I can’t quote a price for similar services at my practice off the top of my head, but I will surely check on Monday for my own education.
I assume that you eventually recovered. Thank you for the well-written article.
Pitfalls for doctors too. I am n ot in any networks because I do not want to be beholden to the idiot insurance carriers.
When they ask me to produce records so they can snoop on my care, I tell them to buzz off, since I am not in the network.
The pitfall for me is that the insurance carriers pay much less but sorse yet, theysend the checks to the patients, to punish me for refusing to “join” the network, aka conspiracy.
The patients then think these checks are their money and pay me nothing.
I am happy to take the 80% if the patient turned over the checks. I often write off the 20% depending on circumstances.
20% is what I will forego for my independence from the a$$hole insurance carriers. MelG
Today you would at least get some guidance even though you should always check price before you go to a provider. Healthcarebluebook.com provides pricing by zip code for common treatments and procedures. What you get is the price that health plans pay their providers so you know what other patients are paying for what you need done. I’ve used the Healthcare Blue Book multiple times for this and switched providers because the one I’m using or the doctor recommended is just too expensive. Many providers will offer a cash paying patient a discount but you have to ask. Knowing what the fair price is before you get something done can really help.
Think you could change my last name to “Wright” — thanks!
My oh my, simply a case of misidentification. If you were in a hospital with an EMR causing most employees to be decorticate as they blindly trust the computer, you could have been killed and mis-billed.
Think you could change my last name to “Wright” — thanks!
“some law about not charging the uninsured or underinsured any more than they would get from insurance or Medicaid”
No such law exists.
Sadly what you state is the standard of operations in the U.S. and what most people do in metro areas is to join an HMO go to one group and have them ‘manage’ for them. Unfortunately in most of private medicine that is NOT the case. If you are fortunate enough to live near a group like Mayo Clinic, Cleveland Clinic you are up the creek.
Unfortunately health reform does not address any of this. Health Reform is “health insurance reform’.
These issues are unfortunately uncontrollable by physicians except for their own offices. Some office need to post their fees, and some do now. Tell your doctor to do that or you will go somewhere else.
Medical offices should know what labs, xrays are the best value for the uninsured and their fees. (your doctors office should insist on having that information or tell them you won’t refer to them. It is TRUE that the fees for uninsured patients are quoted as higher. If so insist on the same discount they give contracted insurers. This is an obsolete hang over from years ago when physicians upgraded their fees so their average charges were higher because medicare’s original formula was to pay 80% of the UCR (usual and customary fee) I agree with Theora, this is disgusting to have a sick patient have to deal with this, It has nothing to do with ‘accountability’. There is almost no way for a patient to negotiate this system. The bureaucrats have taken over the system, and most physicians are ‘burned out’ by these issues if they have been practicing for any amount of time. Glad you have some coverage. What did the problem turn out to be?
The lab violated some law about not charging the uninsured or underinsured any more than they would get from insurance or Medicaid. They ripped you off. You should file a suit in small claims court.
Also, check with the health insurance company as to what criteria they use, actually, to credential and filter for quality, the doc you saw who is in network.
The insurance carrier will punish you financially for going out of network to a doctor who is better.
All you needed was an antibiotic for a week or two, eg doxycycline, which is free at certain pharmacies in the north east.
You did not need a CT to get the rads. If anything, you would have been diagnosed with a three view plain sinus xray.
You also never needed the blood tests. Were there any abnormalities?
You should file a complaint with the insurance carrier about the incompetent doctor, and then file a complqint with your state’s DOH, and insurance commissioner.
Did the doc get a kickback from the CT company, or some other incentive from his “master”?
One more thing, did the doc have his face glued to an EMR screen?
Hope you are feeling better. What was the diagnosis?
I am just a country doctor.
I am a single payor advocate, but I wonder why this isn’t fixed with some simple legislation:
any provider’s self pay rate should be defined by the lowest negotiated rate (x1.5 or x2 if price is the issue), plus price transparency at service. I am a physician, not a clinic manager, but this should be very doable.
You mean the invisible hand of the market didn’t help you negotiate lower prices? I wish I was surprised. Your experience in delaying care and paying exorbitant hidden prices are similar to mine while on a high-deductible plan.
You did have $3k sitting around before you got coverage right?
Excellent point, Theorajones. Don’t forget the docs you never see, such as the radiologists and pathologists. Even people who’ve been in medicine their entire lives fall into this pit.
I can’t get over how many pitfalls there are for patients. My favorite one of these is when you’re having surgery and the doc and hospital are in-network, but oh, the anesthesiologist isn’t! Who’s the anesthesiologist, you ask? Oh, he was the guy in the mask who you’d never seen before your surgery and will never see after. No, not that one, he was a resident. No, not that one, he was an orderly. The one who held the mask, remember? Yep, that guy.
Seriously, what is a patient supposed to do here? Naked, terrified, laying on an operating table, are you supposed to poll the room to make sure everyone is in network? That the instruments and sutures are pre-certified for this kind of operation? That the emergency drugs they will administer to you while you are passed out are on formulary–are you supposed to magically rouse yourself as you’re crashing? And is this before or after you execute your responsibility for making sure everyone is following infection protocols (did you wash your hands?) and doing the pre-surgery checklist and not in an impaired state (I’d like to see the surgeon walk this straight line and touch his nose, please…)
If I hear one more ignorant libertarian promise us how we’re ushering in a new era of responsibility and patient empowerment by pulling more money out of sick people’s pockets, I’m going to vomit. This is a total nightmare, and it’s utterly offensive as well as ludicrous on it face to pass the buck to sick people. Its like putting a classroom of kindergartners in charge of education reform. 95% of patients are wholly unqualified to do quality improvement and cost containment at their healthiest, and the small group that could take on this gig is being asked to reform our health care system while LYING NAKED ON A COLD GURNEY, PRAYING NOT TO DIE.
Standard operating procedure really borders on larceny.
OMG, Mr. White, I feel your pain and I am sorry to hearing that. You are not alone in the world of greedy medical bills and healthcare crisis. I just had a routine dental cleaning a month ago, and I received a bill of $125.00 from the dentist. According to the insurance, I do have a yearly deductible of $150.00 and my yearly benefits is $2000.00. SInce I didn’t see the dentist the whole year until December, I pay this visit as yearly deduction. I guess this is my fault, but I did make a stupid mistake.