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The Ultimate Sacrifice

An estimated 60% of American bankruptcies result from overwhelming medical costs. My uncle’s tale illuminates the dual tragedy of suffering catastrophic illness and being uninsured.

The 2008 recession claimed my uncle’s job, health benefits, and assets, except for a small inheritance. By 2009 he found work (but not health coverage) as a consultant.

One day he noticed that his eyes were yellow. He emailed a photograph, and I immediately recognized jaundice. I calmed him by suggesting benign causes such as hepatitis, gallstones, or liver cirrhosis. But I secretly dreaded a liver or pancreas cancer, given his recent weight loss and itching.

Laboratory and x‐ray tests, which he charged to his credit card, all suggested cancer. His doctor in New Jersey indicated urgent surgery was necessary. An appointment was unavailable for weeks at the county hospital, and private surgeons wouldn’t see him without a cash deposit. Time was ticking. Cure was already unlikely, and delays were allowing the tumor to grow. He decided to travel to the West Coast to expedite surgery.

My uncle arrived around midnight, glowing yellow; he had worn sunglasses to avoid frightening other airline passengers.

He was immediately admitted to undergo a procedure to identify the site of blockage and insert a plastic stent to drain bile externally. While awaiting the outcome, I had a premonition that the worst was yet to come. The doctors brought dreadful news that a massive tumor, too large to remove surgically, lay centrally in the liver. The remote possibility existed of a benign condition masquerading as cancer. The aggressive option was upfront chemotherapy and radiation to shrink the tumor, for possible surgery afterwards. But several surgeons deemed the case hopeless, and estimated my uncle had only 6 months to live. They recommended hospice, and a more comfortable internal metal stent. My family chose not to share these findings with my uncle until he recovered from anesthesia.

The crushing blows continued. Within 36 hours, my uncle lapsed into a coma from kidney failure induced by bile toxins. Knowing the costs, we refused transfer to the ICU. Dialysis was necessary, but the nephrologists regarded the situation futile and refused treatment, comforting us that dying from kidney failure was painless. Miraculously, he rallied. Seeing improvement, the nephrologists started dialysis. We could finally share with my uncle the difficult choices ahead.

He responded “It’s hopeless. Why risk money that could provide my daughters’ education?” He asked to be made “do not resuscitate”, and declined surgery. Two weeks of recuperation made transfer to less expensive skilled nursing care possible, but here I learned it takes money to save money. Ambulance transport was mandatory, costing $1700. As I read the dispatcher my credit card information, I wondered if I could have driven him myself.

In the following days, we tried everything to minimize costs. My uncle had a fever, but refused evaluation in the ER, and was treated with blankets and oral antibiotics. His fever broke, as did the stitches on his stent, which I re‐sutured at the bedside.

In the end, my uncle made the ultimate sacrifice for his daughters by rationing his care. Death came swiftly, only 72 days after he became jaundiced. He never received metal stents, or saw New Jersey again.

His final medical bills totaled over $250,000. Charity care was denied, and MediCal unavailable since he was from out of state. After receiving a 20% discount for paying in a lump sum and in cash, we negotiated a final 40% discount.

The costs of his care can be translated as follows. Each session of dialysis equaled a month of private college tuition. Each day’s blood work would have provided a year of textbooks. The daily hospital room charge would pay for a half‐year in the dormitory. The anesthesia fee would have purchased a full year’s meal plan.

My uncle’s cause of death remains unknown. Weeks into treatment, his tumor markers came back normal. Surgery might have been curative, or confirmed a hopeless situation. The cost to know with certainty would have consumed his inheritance. The World Health Organization recognizes this universal tragedy worldwide: “The poor are treated with less respect and given less choice of providers. In trying to buy health from their own pockets, they pay and become poorer.”

Whenever someone faults the medical system for the epidemic of bankruptcies, I ask instead: My uncle was 59, and for decades had contributed to the system by paying health insurance premiums while employed. Did the system treat him fairly when he needed care?

John Maa, MD, is Assistant Professor of Surgery at the University of California, San Francisco.

Cost of Care:
On Labor Day 2010, 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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29 replies »

  1. Jenn read the article again. The money was there, they paid $120,000 cash. They had the money, they spent 6 times more then what COBRA was.

  2. Just because COBRA is available doesn’t mean it can be paid. If the choice was a roof over their head and food on the table or medical insurance, the medical insurance is really not practical. So yes the $21,000 is a lot less than $120,000, but if the money isn’t there, what choice do you have? You can’t pay premiums with money you don’t have…

  3. I am upset about this on so many levels. Yes, the uncle probably could have bought COBRA insurance, but COBRA probably would not have been an option if the company he worked for was small, or if the company went out of business. And to Nate, the cost of PPO insurance for a 55 year old in California is closer to $1000 a month for one person, $2000 monthly for a family, not the $500 you use. Uncle was 59 and probably would have had even higher cost.

    If the uncle had acted like millions of unresponsible people, and just showed up in the Emergency Room he probably would have gotten adequate care. The ERs are full of unresponsible people, including many illegals, who just show up and get free medical care they have no intention of paying for. This hard working uncle tried to be responsible and make an office appointment, which would have led to intolerable delays. If we did not have so many illegals draining the system, neither the county clinics nor the ER would have so many delays.

    The $250,000 final bill was I’m sure almost all inflated hospital bills and physician charges were likely only a small portion. If he had Blue Cross PPO, most of these excess charges would have been slashed to a small portion of the total bill. When I needed emergency surgery years ago, the initial hospital bill was $20,000 but after my insurace discounts were applied, the insurance company paid the hospital only $2,800 and I only had to pay $300. Thus the hospital gave an almost 80% discount because I had insurance but had I been uninsured, I would have owed the entire $20,000.

    I am also upset about all the laws demanding that health insurance pay for all sorts of things such as preventive care, etc. Of course it is nice when insurance covers it, but it drives up the cost of insurance. The uncle probably could have afforded a bare bones policy for catastrophic illness, and it would have covered this.

  4. “The definition uses the term “chronic” to capture only those conditions that are long-term in nature. Your doctor will be able to help you identify whether a condition is chronic or whether it is acute.”

    Nate, it appears he would not have been covered anyway from the text of the definitions used above. If things like cancer were used as pre-existing then why buy any insurance, just sign up when you have catastrophic. I like that plan as when the Republicans defeat the mandate but keep the rest of the “popular” aspects of the bill I will use it to the fullest. :>)

  5. “I don’t think Dr. Maa’s uncle would qualify as death is not a pre-existing.”

    No but the condition that killed him would.

    ” I did look at the plan and wonder if even he could afford it. ”

    Did you miss the part where they paid the hospital $120,000 cash becuase he didn’t have insurance? $120,000 cash payment and you wonder if he could afford $440 a month. FYI ya he could have afforded at least 272 months worth.

  6. I don’t think Dr. Maa’s uncle would qualify as death is not a pre-existing. I did look at the plan and wonder if even he could afford it. The cheapest plan for his age is $440/month and he is on the hook for $5000 of uncovered charges. That’s about $10,000 per year. I guess it would come down to how much of his inheritance he was willing to part with. If he couldn’t afford a non-preexisting plan how can he afford this? It still appears to me that no amount of money could have saved his uncle from this cancer.

  7. WRONG

    NYTimes says OWEbama is a DECEIVER —

    http://www.nytimes.com/2009/11/25/health/policy/25bankruptcy.html

    ” .. How many personal bankruptcies might be avoided is unpredictable, as it is not clear how often medical debt plays a back-breaking role. There were 1.1 million personal bankruptcy filings in 2008, including 12,500 in Nashville, and more are expected this year.

    ” .. Last summer, Harvard researchers published a headline-grabbing paper that concluded that illness or medical bills contributed to 62 percent of bankruptcies in 2007, up from about half in 2001. More than three-fourths of those with medical debt had health insurance.

    ” .. BUT the researchers’ methodology has been criticized as defining medical bankruptcy too broadly and for the ideological leanings of its authors, some of whom are outspoken advocates for nationalized health care ..”

    OweBama, no one with a brain believes a word you say.

  8. 10%-20% fraud?
    trillion in unfunded promises?
    inadequate coverage and protection?

    “It would certainly work for me.”

    That doesn’t surprise me at all Margalit. Have you always hated your kids and grandkids or did it develope over time?

  9. “Social Security Premiums?
    Medicare Premiums?
    Taxes?”

    Let’s make health insurance work the same way as the above, Nate. Would that work for you? It would certainly work for me.

  10. “What would change if employers gave every employee a $3600 raise then left it up to them to buy insurance?”

    “cost would sky rocket”

    But Nate, wouldn’t that be equivalent to Republican voucher system. Wouldn’t the heath care industry finally see there were no deep pockets and reduce costs/prices? Wouldn’t that promote consumer driven health care? We could all just go to the insurance exchange. Isn’t that the controls you’re always pushing for?

    “tens of millions would pocket the money instead of buying insurance
    The cost of insurance for those that did buy it would not be affordable”

    But Republicans don’t want insurance purchase mandates. Why should you be forced to buy your employer’s health plan?

  11. “The real problem stems from the fact that health insurance is intertwined with employer benefits. It’s ludicrous that you must rely on your employer for health.”

    Does this also apply to;

    Life Insurance?
    Unemployement Insurance?
    Social Security Premiums?
    Medicare Premiums?
    Taxes?

    What would change if employers gave every employee a $3600 raise then left it up to them to buy insurance?

    cost would sky rocket
    tens of millions would pocket the money instead of buying insurance
    The cost of insurance for those that did buy it would not be affordable

    What exactly would be accomplihed by decoupling employement and insurance?

  12. As we have watched the progression of health care reform, please keep in mind that the primary purpose of Health Care Reform was to get people without access to coverage, access to coverage. Which is great, but can it be affordable? At this time, some employers are taking the initiative to investigate and implement limited or fixed benefit plan options.

    Do you currently cover all of your employees? OR, do you currently carve anyone out of the plan based on their employment classification?

    The law does allow you to offer a limited plan when affordability is an issue. This allows restricted annual limits on essential benefits; if there is a significant decrease in access to insurance, or if an increase in premiums becomes a factor. Keep in mind that these are NOT major medical plans.

    There is a waiver process in some cases. If you currently have a limited benefit plan in place, and kept it, you have already experienced the waiver process. If you do not currently offer a limited benefit plan and would like to implement one, here are three potential options.

  13. The real problem stems from the fact that health insurance is intertwined with employer benefits. It’s ludicrous that you must rely on your employer for health. As Americans, would we accept our employers to own our homes too, as they do in Russia? The health insurance reform legislation of 2009 only further bloated the leverage employers have over their employees when it comes to health insurance. The best thing the government could do is remove the tax breaks and establish a more operational independent health insurance market so that people like your Uncle won’t have to lose coverage along with their job.

  14. Much of Medicaid is paid for by the state so the rules are dictated by the state. I wonder what the median income and cost of living is for NJ?

    “Many of our hospitals check the potential Medicaid status of every self pay patient admitted, and more often than not, the patients are eligible for some form of coverage.”

    You’ve go a problem with that?

  15. He may have qualified. The most recent eligibility requirements for 2011 are more strict than in previous years secondary to budget constraints. The “asset” test states;

    “Certain assets are exempt in determining Medicaid eligibility. These include home and household effects, life insurance under $1,500 per person and one car valued at $4,500 or less.” (http://www.hrsa.gov/reimbursement/states/new-jersey-eligibility.htm)

    Many of our hospitals check the potential Medicaid status of every self pay patient admitted, and more often than not, the patients are eligible for some form of coverage.

  16. “The 2008 recession claimed my uncle’s job, health benefits, and assets, except for a small inheritance. By 2009 he found work (but not health coverage) as a consultant.”

    “AND the hospital’s financial counselors would have applied for Medicaid for him.”

    Have you looked up NJ’s Medicaid eligibility requirements? I doubt he would have qualitfied.

  17. Shame your uncle didn’t stay in New Jersey. They have one of the most comprehensive Medicaid programs, open to the most individuals. And your uncle could do what patients do all over the US under our current “universal healthcare” program and show up to the ED. Once admitted, he would have received the care he needed AND the hospital’s financial counselors would have applied for Medicaid for him.

  18. “The costs of his care can be translated as follows. Each session of dialysis equaled a month of private college tuition. Each day’s blood work would have provided a year of textbooks. The daily hospital room charge would pay for a half‐year in the dormitory. The anesthesia fee would have purchased a full year’s meal plan.”

    I guess I’d like to know what type of MD Mr. Maa is where he works and how much he makes because if he’s complaining about cost he could be a large contributor (and benefactor) of that.

    “The doctors brought dreadful news that a massive tumor, too large to remove surgically, lay centrally in the liver. The remote possibility existed of a benign condition masquerading as cancer. The aggressive option was upfront chemotherapy and radiation to shrink the tumor, for possible surgery afterwards. But several surgeons deemed the case hopeless, and estimated my uncle had only 6 months to live.”

    So, was this a hopeless case where no amount of money would have given a good outcome?

  19. Nate – I’m one of those rare people who care about what services, tests, procedures and drugs cost even when my insurance company is paying. I wish there were a lot more of us. Hopefully, over time, there will be.

  20. $250,000 was spent without insurance and going to great lengths to minimise cost, actions that most assuridly would not have been taken had he been sufficently insured. This illustrates the problem with third party payment. When spending someone else’s money they would have gone through $250,000, $500,000 or even a million without a second thought. But when it was their money and it impacts what they pass on to kids then cost is a major consideration. If this had been a million dollar insurance claim where do people think that money would have come from?

  21. This is a classic example of what people need health insurance for the most – the catastrophic event or episode. I also wonder why COBRA wasn’t picked up assuming it was available from the former employer. Employers with fewer than 20 employees and certain church plans are exempt from COBRA rules.

    The discussion of the cost of this medical care reducing or eliminating the ability to finance a child’s college education is spot on, I think. It makes the point very clearly that (1) resources are finite, (2) there are other worthwhile uses for money besides medical care including education, infrastructure modernization, maintenance and repair, and environmental cleanup, among many others, and (3) we can only spend a given dollar one time. I would carry this argument a step further and extend it to medical care that is covered by insurance as well, especially Medicare and Medicaid coverage. Does it really make sense to spend six figures to try to slightly extend life for a 90 year old dementia or cancer patient who has already lived a normal lifespan and then some and whose quality of life is now poor and unlikely to improve when there are so many other legitimate competing needs for the money? I’ve said many times that financial resources are finite and the value of a life is not infinite. That includes my own and my wife’s. I think patients, especially the elderly, need to rethink their expectations and doctors need to rethink their end of life care practice patterns.

  22. 250K times .8 is $200,000 times .6 totals $120,000 in the end which you claim was paid in cash.

    You don’t say when in 2008 he lost his job so lets pick the middle, July 1, 2008. Even in high cost NJ single COBRA would most likly not be more then $500 a month. 18 months would have taken him to Jan 1, 2010. At that point he would have qualified for a HIPAA plan no matter his health at $1,000 a month. COBRA would have cost $9,000. 12 months of HIPAA another $12,000. Worst casr scenerio for $21,000 he would have been insured and had access to the best care in the world. At minimum he would have had a million dollars to spend.

    How can you pay cash for his $120,000 of care but not have afforded $21,000 for the insurance? The failure was thinking you can skimp on the health insurance premium to save money and pass something on to family. When the gamble failed now all of a sudden it is everyone else’s fault.

    $21,000 in premium would have prevented all this, some how that fact never gets raised in these contest.

  23. “An estimated 60% of American bankruptcies result from overwhelming medical costs.”

    Then this political claim was so thoroughly debunked people stopped using it. But still on occasion rears it’s propogandist head. The true number is no where close to even 20%. Medical bills on average make up a couple thousand dollars of total debt in a bankruptsy.

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