Three Ultrasounds

Sitting in an exam room I am watching my patient struggling to ask a difficult question that she clearly does not want to ask. After several attempts at starting and a few half finished sentences she finally manages to mumble a request for help with obtaining food for herself and her two daughters. She is a 41-year-old woman, 32 weeks pregnant with her third child, and working a full time job as a CNA in a local nursing home. Her husband is also working full time as a janitor. At her initial visit she denied any issues obtaining food for herself and her family, and declined any referral to social services.

“Has the work situation changed for you or your husband?” No. “Have you always had difficulty getting food and did not want to ask?” No. “Is there some reason you need more food than you needed before?” No.

Tears begin to flow and she starts to talk. She tells me that she had been in this country for 5 years and never had public assistance of any kind. She talks about her long hours working 2 and sometimes 3 jobs in order to have enough money to keep her family afloat. She talks about putting herself through school to become a CNA while still working to pay her bills. Until last year she was doing this alone, making not only money to provide for her family, but also the money needed to bring her husband here. She had never asked for help or let her children go without. But now she is unable to pay her bills and buy food. What is the tipping point for her ability to provide for her family?

Three ultrasound bills from this pregnancy.

She is 41 and had opted for an early screening test at 12 weeks that combines ultrasound and blood tests to give an estimated risk for Down Syndrome. She made this decision after a visit with a genetic counselor and had the test despite the fact that the results would have no effect on the outcome of her pregnancy.

At 18 weeks she had a fetal survey ultrasound that patients have routinely to check the anatomy of the baby and rule out anomalies.

At 30 weeks she had an ultrasound to check the growth of her baby because she was over age 40. This is following hospital protocol; despite the fact that there was no clinical indication her baby was anything but well grown.

This patient had private insurance through her job. Very few of my patients have private insurance, and at that time I worried less about a patient with a full time job who had private insurance meeting her needs than I did about a patient on welfare with state insurance. It didn’t occur to me to ask a patient if her medical bills were paid in full, or if she was responsible for paying a percentage or had a deductible.

The patient had insurance that would pay 80% of procedures, including ultrasound. Her insurance had deemed her 18-week fetal survey as necessary and were paying 80%, the other 2 ultrasounds were not considered necessary. She had a bill for close to $1400 that she had been paying off weekly for three months.

It could just have easily ended up that I would never have known about these bills, and in fact that may have been the case in the past with other patients.

We almost never think about what a test costs or whether it is paid for. Trying to find out the cost of a test is sometimes almost impossible. We almost never stop to think if a test is really indicated, or if the results will change the course of their treatment.

As providers we order tests because they are there, or because it’s easy, or because everyone gets them, or because we are scared if we don’t we’ll be sued, or because of arbitrary protocols. Sometimes we order tests because it’s the best thing for a patient.

No one orders tests thinking we might be taking food out of the mouths of our patients and their families, but sometimes that is exactly what we are doing.

This anecdote originally appeared at Costs of Care, and is a finalist for their essay contest.

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).

24 replies »

  1. 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: Three Ultrasounds…

  2. Luckily it will take many more years to get to gov. run health care Jane. Peter will have to wait a bit longer.

  3. “Okay Peter—can it work the other way around. The hospital finds out upfront the patient can’t pay for the care and then the patient doesn’t get the care.
    Or gets a lesser treatment they can afford. How is that?”
    Actually Jane, I’m not for door #1 or door #2. I’m for government run/controlled single-pay where the ability of the patient to pay has nothing to do with getting the proper and needed medical treatment. That way you get paid, the hospital gets paid and the patient gets care.

  4. If this discussion were about some obscure medical problem the focus on costs would make sense. But for routine prenatal care it simply illustrates the train wreck which results when health care is treated as a commodity. Health care in one of the world’s richest countries should be as available as safe drinking water and proper engineering of highways and buildings. There is no excuse for stories like this.
    And as for that “defensive medicine” trope, that problem would vanish with specialty best practice standards. Unfortunately, the “best practice” currently is that which generates the biggest revenue stream instead of the most good outcomes. And defensive medicine only spins the wheel faster. The metric should be adherence to best practices with checklist documentation. In fact, video records might be something to consider… assuming there is nothing to hide.

  5. “I do not understand why it is so difficult for people to know what is and isn’t covered.”
    There are only two possible explanations: 1) either most patients are stupid (or not as smart as Jane) or 2) the system is so confusing, price opaque, intimidating, and misleading that most patients end up doing something that is against their financial interest.
    Either way, it would help everyone involved to offer more price transparency and clearer guidelines for patients with different financial means.
    As is often the case with people of limited income and education, this poor lady probably had no idea whether the 3rd US was critical for her baby’s health or not. She probably was too intimidated to even ask or question the doctor. A consumer-friendly health care system would have provided her the right information (in a manner she could understand) to help her make the right decision.

  6. Okay Peter—can it work the other way around. The hospital finds out upfront the patient can’t pay for the care and then the patient doesn’t get the care.
    Or gets a lesser treatment they can afford. How is that?

  7. Susan, the patient’s ability to pay is also their ability to follow the doc’s treatment. If you’re interested in wanting the best care for the patient, then knowing if they can afford the treatment is part of the care.

  8. Well I guess this young woman will have to make a budget and pay her bill. It isn’t others responsiblity to make sure she has coverage. I do not understand why it is so difficult for people to know what is and isn’t covered. The benefit booklet I get every year clearly states what will and won’t be paid. How is it the hospitals responsibility to read her insurance coverage for her?

  9. Susan, ballpark figure is fair enough.
    As to the patient, I don’t think it is as simple as saying that it’s not your job to make sure the patient can pay.
    In this particular case, how was she to know that she cannot afford those ultrasounds? How was she to know that she needed to do homework? She had insurance and I am willing to bet that she was told that the insurance will pay.
    I think people fail to realize that a sizable number of folks are unable to navigate this convoluted, profiteering, and frankly, uncaring health system. This particular lady was one of the vast majority.
    I don’t know in what settings she was seen, but you don’t ask every well insured patient if they have enough food or if they want a referral to social services. The clinic must have had enough financial information to classify the patient as needy.
    Doesn’t the hospital have a policy for needy people to go along with its policy for mandatory ultrasounds?

  10. Furthermore Margalit–you have the quack doctor above who isn’t even in private practice ignorant of the costs.

  11. @Margalit,
    You are wrong about private practice. I have no idea what things actually cost. A ballpark figure maybe, but not actual cost. Look it isn’t my job to make sure the patient can pay. Doesn’t anyone take responsibility for themselves anymore. She should of known that she couldn’t afford one US after another. For the love of God can’t you people look after your own finances. This wasn’t an emergency situation and she could of done her homework.

  12. First, this lady is in no financial position to have a third, maybe even second child. But that is not the issue for docs who order treatments without knowledge of costs to patient. I agree with Barry, “they just don’t consider it part of their job to know or care about costs”. It’s not only people docs, few vets care or know of their treatment costs as well, even more critical because many people will opt for no treatment or death for their pet. My vet said she’d be afraid that if she presented cost the owner would not get the needed pet treatment – but she fails to understand that will happen anyway.
    The process of getting cost information is also cumbersome as you are referred to the “business manager” or “accounts” which puts patients away from any discussion on care options along with costs. I had a PCP urgent care doc once prescribe a cough med as part treatment for a lung condition. The med was $85 but the cough was maybe a $10 cough. Follow-up appointment the doc asked if I was taking the cough med and I explained to him the price and that I was recovering just fine without it.

  13. I second Barry Carol’s comment. Love to tell my story where my daughter’s dermatologist prescribed 75 mg doxycycline b.i.d for acne, which cost literally 10x as much as 100 mg in the morning and 50 mg at night for same total. He was ‘shocked’ when I called him up and told him. Think he changed his prescribing habits? Highly doubtful.

  14. I do generics whenever possible, but I don’t know how much those cost, either. I’m a doctor, not an accountant. This is a big reason why I shied away from private practice/for-profit medicine.

  15. Oh, no. Doctors in private practice know exactly how much everything they do costs, or at least how much everything gets reimbursed. Sometimes they don’t know the costs of tests that are ordered outside, but many times they know full well that the big hospital charges more than anybody else.
    Real time claim adjudication will not help much for these things because you have to first perform the service before you send the claim for adjudication.
    Dr. Vickstrom, you do prescribe generics, don’t you? So you are supposed to know…..

  16. Truth be told, I seldom know the cost of what I’m ordering. I’m not actually supposed to know. I’m just supposed to do the most high quality, minimal risk medicine I know how.

  17. In my considerable experience as a patient as well as that of friends and colleagues, more often than not, doctors don’t have a clue what services, tests, procedures and drugs cost, including, sometimes, tests and procedures they perform themselves in their own office. The reason, as far as I can tell, is that they just don’t consider it part of their job to know or care about costs. They see their job as diagnosis and treatment and, if necessary, referral to a specialist or admission to a hospital. Moreover, they assume, often incorrectly, that the vast majority of the bill will be covered by insurance. Even when patients attempt to ascertain the cost of services before they are rendered, it can be difficult or impossible to find out. User friendly price transparency tools would be helpful here as would a different mindset regarding costs throughout the physician community. Determining whether or not a particular service, test or procedure is covered by the patient’s insurance policy is a separate issue but it should be easier as real time claims adjudication technology becomes more widespread.

  18. I have to agree with Mark here.
    It is not clear to me who ordered those ultrasounds, since the author seems to think they were not necessary.
    The first one occurred after a genetic counseling session (what was that for, and who paid for it?), but everybody involved seems to have known that the patient will not terminate the pregnancy if the results were positive, so why order the test? It says that “she opted” to have the ultrasound. Did she really? Or did she “agree” to have it just to avoid conflict with the counselor or doctor? And why doesn’t anyone think of checking if the insurance of a clearly poor person will pay for fancy elective tests? Obviously the subject of social services came up before. Did they just think that the lady who may need assistance with food, has a Cadillac plan from work?
    The third ultrasound, which was also not covered, was done per “hospital protocol”. I have no idea what that means, or why the hospital gets to dictate this stuff, but it sure came with hospital pricing.
    These ultrasounds would probably be counted as patient demanded over-utilization and also as defensive medicine. I’m afraid they are neither. The patient was intimidated into complying with a mindless protocol that is aimed at increasing hospital revenue.

  19. @Mark Spohr,
    “This patient is starving because of the greed of the caregiver and the caregiver is acting like she has no responsibility for the problem.”
    Your statement assumes that the caregiver benefits from ordering the procedure. That is not necessarily the case.
    “No one orders tests thinking we might be taking food out of the mouths of our patients and their families, but sometimes that is exactly what we are doing.”
    The tragedy is that we have designed a system in which if the physician orders the test, she is taking money out of the patient’s mouth. If the physician doesn’t order the test, it will be the patient taking food out of the physician’s mouth. Our current system tries to make the physician the patient enemies. Not much we physicians can do about it but resist it all we can. And cover out buns as best we can.

  20. What surprised me about this story is the complete lack of insight on the part of the storyteller (and caregiver) into her role in the drama.
    The patient may very well have needed all of the ultrasounds but it appears that she was grossly overcharged. Ultrasounds usually cost about $150-$200 but she seems to have been charged $1400 for the second and third ultrasound. The caregiver acts as if she had no role in these excessive overcharges and was powerless to mitigate these charges.
    When I read this story I think “This patient is starving because of the greed of the caregiver and the caregiver is acting like she has no responsibility for the problem.”

  21. Ah, yes. But, that defensive medicine test ordering suddenly becomes a life-saving, necessary test the moment that 1:100,000,000 chance comes off, and a bad outcome occurs. How do you tell which one it is before you do the test, eh?

  22. Thanks for sharing your experience. The lack of price and cost transparency in the US is a major impediment to realizing the the benefits of the ‘free market’. I disagree with making patients feel like criminals if they don’t agree with physician’s ordering of tests mainly to decrease their personal liability risk (‘there is a small chance your baby will die if you don’t get this test, but you can refuse if you want. However I will document that in your chart in BIG BOLD LETTERS so if it does happen everyone will blame you and not me’).

  23. This is the great shame of the USA. We as a society should be ashamed we let things like this go on. And now we have record corporate profits while stuff like this goes on. Conscience, anyone?
    A doc has to practice all the defensive medicine s/he can. No sin in protecting yourself. That being said, the patient always has the right to refuse all those extra tests. They need to be reminded of that.