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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).

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Al KennedyJohn BallardPaoloJaneSusan Recent comment authors
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Al Kennedy
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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…

Susan
Guest
Susan

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

Peter
Guest
Peter

“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.

John Ballard
Guest

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… Read more »

Paolo
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Paolo

“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… Read more »

Jane
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Jane

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?

Peter
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Peter

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.

Jane
Guest
Jane

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?

Margalit Gur-Arie
Guest

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… Read more »

Susan
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Susan

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

Susan
Guest
Susan

@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.

Peter
Guest
Peter

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… Read more »

bev M.D.
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bev M.D.

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.

Buy Seroquel
Guest

Thanks for sharing this blog.. Thanks..

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

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.