[Sparkletron]

With so much discussion and interest over the movie, Sicko, I wanted to post an anecdotal (and personal) example of health care corruption here in the US.

Like many of us, I receive my benefits as part of my employment compensation. My particular provider is Aetna.

Recently, I stepped on glass and was pretty sure I got some in my foot. I went to an urgent care facility where they collected my copay of $20 and led me in to see an MD. To be fair, I was very impressed by how quickly this happened. My regular doctor generally keeps me waiting 30-45 minutes--and that's with an appointment! This care facility was very busy but still managed to attend to me within 5 minutes.

Anyway, the MD said I had two choices: live with it and the glass will eventually come out on its own or have the glass removed. I asked her, "What would you do? Would you want to leave glass in your foot?" I wasn't even certain that there was glass or how much or how deep, etc. The MD suggested an x-ray. Brilliant! So I got an x-ray, which cost me another $20 copay. The MD looked at the x-ray and confirmed that I did indeed have glass in my foot. Unfortunately, there were no surgeons available so I would have to return. I didn’t mind too much since the injury was not life-threatening and I could survive for a few more days.

Two days later I copaid another $20 and saw a new MD who performed the surgery. He told me to come back in a week to have the stitches removed.

A week later I copaid another $20 and had the stitches removed.

Now this last copay bothered me. I understand the concept of a copay, which is ultimately to limit abuse by putting some of the burden of health care on the patient regardless of insurance, lest the patient believe these services are somehow free. But in this case the stitches were not an elective procedure; they were part of the surgery. Charging me $20 for the surgery and another $20 to remove the stitches seemed abusive.

So I called Aetna where they told me that my policy requires $20 for each office visit regardless of how many visits a procedure is spread out over. By this reasoning, anything involving sutures or a cast is $40 minimum unless you want to remove them yourself...

I then questioned why I had to pay an extra $20 to come back for surgery that they should have provided me during my first visit. I mean, technically, I didn't receive any urgent care for my first $20. I came in with glass in my foot and left with glass in my foot. I was diagnosed but not treated because they claimed they had no one available to treat me just then.

Then there's the x-ray. It turns out Aetna covers that completely and no copay was required! But the urgent care facility demanded it anyway. And I have not gotten it back.

Whether I overpaid by $20 (according to Aetna) or even $60 (as I believe) is not going to impact me financially. But when you consider this as a systematic practice applied to thousand of patients every year--the money adds up. Can I file a lawsuit and write Congress and start a grass roots movement to reform health care. Sure I can! Will I? Most of us, I believe, will do as I did: spend a reasonable amount of time on the phone and then give up in frustration (Aetna blames the clinic; the clinic blames Aetna; I lose). Or perhaps not even that. Perhaps most of us just pay and are happy the $60 wasn't $600. It's likely these statistics are already part of the profit/loss calculations used by the health care industry. They know a small percentage will complain and the rest will accept the overcharge.

Incidentally, it was interesting to see what the urgent care facility charged and what Aetna paid. The two were vastly different. Walk in without coverage and your immediate costs will be around $500. That's before an MD has even said hello to you. Aetna knocked that down to $130. Now it doesn't surprise me that Aetna, representing perhaps millions of patients, can collectively bargain and receive a discount. But that kind of discount clearly demonstrates how much those without insurance are being overcharged. No way can $500 reflect the actual cost of "services" when Aetna only pays a fraction of that amount.

The bottom line is that there is real abuse happening in the health care industry. It's not particularly exciting; it doesn't involve exotic locales or crazy stunts or pit the forces of socialism against the forces of libertarianism or what have you. It's not a clash of geopolitical socioeconomic ideals. It certainly doesn't make for a good movie. But it is real. It's small and subtle and algorithmic, and works by fraudulently extracting very small amounts from very large numbers over time.

-S

[OldManMac]

It's a nice racket, and the "care" industry gets away with it. When a hospital charges $3 for an aspirin, and $10 for slippers, and on and on, something is wrong. But, according to some, there is nothing that needs fixing, and everybody gets necessary health care, whether they're insured or not.

[Dakarʒ]

No offense, but this almost sounds like a chain email. Almost.

[Big Mac]

ZOMG, that sounds like tremendous abuse! You're complaining about $60? Are you serious?

[Dork.]

I've given up trying to understand how and why the Medical profession does their billing. I recently changed jobs, and I have one of those "Health-Care Reimbursement Accounts" which I load up since I get allergy shots two or three times a month at $20/pop in co-pay. My new job uses the same company to administer these accounts that my old company did. After changing jobs, I dutifully filled out all the paperwork to fund my new account and make claims on it -- only to find the money was still coming from my old account! It turns out that even though I'm not paying any money into the old account, my old company is still liable to fund the account up to the limit I set. The company administering the account wants my old company to go through many hoops to close the old account, which they say they did, but the administrator says they didn't. I gave up trying to resolve this after a week. So now I have one reimbursement account which I'm not paying any money into but getting money out of, and a second which I am paying money into which I'll never see again.

And when my wife was pregnant, she had some complications and had to see the doctor once a week, and then get a "Non-Stress" test once a week, too. The office where the NST was given was a side business of my wife's doctor, and there was even an inner door that shuffled patients between the two offices. But two offices = two visits = two co-pays!

And don't even try to ask questions about your spouse's bill that got screwed up: they all hide behind HIPPA as a reason to not give any information out, ever.

[Sparkletron]

Originally Posted by Dork. 

and there was even an inner door that shuffled patients between the two offices. But two offices = two visits = two co-pays!

Another common abuse is the ritual of having to wait in the reception area for at least fifteen minutes (regardless of your appointment) and then wait at least another fifteen in the examination room. Well that time may be your loss but it sure isn't a loss for the doctor; they bill it to your insurance company.

-S

[OldManMac]

Originally Posted by Big Mac 

ZOMG, that sounds like tremendous abuse! You're complaining about $60? Are you serious?

Maybe some people don't have $60 to light cigars with, as you apparently do. Even if they do, some of us don't like to hand out money to others just because they ask for it. You also might want to remember the point he made about how this could be happening to many people, which adds a lot of money into somebody else's pocket.

[greenG4]

Originally Posted by Dork. 

And don't even try to ask questions about your spouse's bill that got screwed up: they all hide behind HIPPA as a reason to not give any information out, ever.

Trust me when I say we are not "hiding" behind HIPAA. If we give out any PHI (Private Health Information) on even a spouse, that is a $250,000 personal fine. I don't know about you, but that's a few years income to me.

[medicineman]

If I understand you correctly, it cost you $80 for an office visit, x-rays, surgery and aftercare. What is the complaint?

[Dork.]

Originally Posted by greenG4 

Trust me when I say we are not "hiding" behind HIPAA. If we give out any PHI (Private Health Information) on even a spouse, that is a $250,000 personal fine. I don't know about you, but that's a few years income to me.

Perhaps saying "hiding behind HIPAA" was a bit too harsh, but many health care providers will err on the side of caution and not give disclosures in cases where it is perfectly legal to do so. Maybe the law itself is to blame, with its vague language but specific penalties, but all I know is that it has caused me more problems since the law was passed.

Hipaa was designed to allow Americans to take their health insurance coverage with them when they changed jobs, with provisions to keep medical information confidential. But new studies have found that some health care providers apply Hipaa regulations overzealously, leaving family members, caretakers, public health and law enforcement authorities stymied in their efforts to get information.

Experts say many providers do not understand the law, have not trained their staff members to apply it judiciously, or are fearful of the threat of fines and jail terms — although no penalty has been levied in four years.

Some reports blame the language of the law itself, which says health care providers may share information with others unless the patient objects, but does not require them to do so. Thus, disclosures are voluntary and health care providers are left with broad discretion.

The unnecessary secrecy is a “significant problem,” said Mark Rothstein, chairman of a privacy subcommittee that advises the Department of Health and Human Services, which administers Hipaa. “It’s drummed into them that there are rules they have to follow without any perspective,” he said about health care providers. “So, surprise, surprise, they approach it in a defensive, somewhat arbitrary and unreasonable way.

http://www.nytimes.com/2007/07/03/he...y/03hipaa.html

[cjrivera]

Here is a SUMMARY (yes, a 23 page summary...) of HIPAA.
http://www.hhs.gov/ocr/privacysummary.pdf

and here is the link to the rest of the HIPAA info...
HHS - Office for Civil Rights - HIPAA

[Dakarʒ]

Originally Posted by medicineman 

If I understand you correctly, it cost you $80 for an office visit, x-rays, surgery and aftercare. What is the complaint?

I think he's unhappy that they're nickel & diming him to death.

[CRASH HARDDRIVE]

Originally Posted by OldManMac 

Maybe some people don't have $60 to light cigars with, as you apparently do.

Lighting cigars? The OP paid $80 for an exam, x-ray, surgery, and stitches removed. I'm sure examples abound of overcharging for medical care, but for the life of me, I can't see where this is one of them. Typically for many people, any one of those things costs more than his entire cost.

Oh, but I know. Let's turn control of our health over to the government so that rather than $80, he can pay multiple thousands of his income dollars in taxes, and then wait in line for the same treatment -or likely, much worse. That'll solve eeeeeverything.

[shifuimam]

You do realize that's what you get with an immediate care center, right? Those places aren't cheap. The services you got there, had you been uninsured, would have been far more expensive than the same services - again, uninsured - at your doctor's office or a regular hospital. The fact that you got to see an MD quickly is defined by the fact that it's an immediate care center - your doctor schedules you and does his best to match that schedule, but the two situations are inherently different.

You're lucky to have the plan that you have, so I don't know why you're bitching so much. You know what my insurance is? I pay $50 a month and I have three deductibles before the 20% copay kicks in. I have a $1000 primary deductible. Then work kicks in $1000. Then I have another $1000 deductible. When all is said and done, if I ever have major surgery, it's going to cost me at minimum $2,000.

<edit>
I should add that for $80 you got a ton of service. You got an exam, an x-ray, the x-rays analyzed, surgical removal of the glass, stitches, and stitches removed. I sliced my finger open with an x-acto knife when I was in seventh grade. My parents took me to the ER of a pediatric hospital. I had to get the wound cleaned and examined and get like eight stitches in my finger. It cost my parents around $600 - and that was with insurance, and that was ten years ago.

So, no. $80 for all the service that you got was an extremely small charge. You should be grateful that you have an employer that provides such an excellent insurance plan.

Think about if this is the only medical emergency you have all year. With universal health care, you'd be paying a shitload more taxes every year to get government-subsidized health care, and you might only use it this one time. That sounds a lot less fair to me, don't you think?
</edit>

[Railroader]

Originally Posted by Sparkletron 

Incidentally, it was interesting to see what the urgent care facility charged and what Aetna paid. The two were vastly different. Walk in without coverage and your immediate costs will be around $500. That's before an MD has even said hello to you. Aetna knocked that down to $130. Now it doesn't surprise me that Aetna, representing perhaps millions of patients, can collectively bargain and receive a discount. But that kind of discount clearly demonstrates how much those without insurance are being overcharged. No way can $500 reflect the actual cost of "services" when Aetna only pays a fraction of that amount.

Your experience is EXACTLY the opposite of mine. I asked my doctor what he would charge me if I paid cash for his services instead of going through insurance companies and he quoted me a price nearly 50% of what he charges the insurance company. He stated that he would save a lot of hassle collecting from the ins. co. and would have more time for patients.

[Dork.]

Originally Posted by Railroader 

Your experience is EXACTLY the opposite of mine. I asked my doctor what he would charge me if I paid cash for his services instead of going through insurance companies and he quoted me a price nearly 50% of what he charges the insurance company. He stated that he would save a lot of hassle collecting from the ins. co. and would have more time for patients.

I think what you'll find is that there is a "list price" that doctors institute for their services which is at the high end (some would say well above) what they would reasonably expect someone to pay. If I had to guess as to why this is, it's because different insurance companies have different amounts they will cover for the same service. Usually, the doctor gets paid the higher of what he says a procedure will cost and what the insurance company says it will cost. So, by "listing" the highest reasonable price for a procedure, they can get more out of insurance plans with higher rate schedules.

You got a lower price because you asked your doctor directly "if I paid cash for this procedure, what would you charge me", and he gave you a steep discount over what he would charge the insurance companies because of the hassle you save him by paying cash. But your doctor doubtless does the same thing, setting his "list price" high so he can get the full reimbursement from insurance.

[Uncle Skeleton]

I only had stitches once, but it seemed like removing them was just the simple matter of cutting them and pulling them out. Why can't patients do this themselves at home?

[medicineman]

Insurance contracts include a fee schedule for every procedure, each with their attendant ICD9 codes. The contract also contains a clause saying, you will bill according to their fee schedule OR your regularly and customary fee WHICHEVER IS LESS. It behooves the provider to bill at a higher rate so as to not jeopardize his contract, and make up for services which are paid at a lower than actual rate.

Where before, you could pop into their office and ask for a note for work, or whatever, they now bill for an office visit, else the insurance carrier would insist that 'their patients' also receive the same 'free' service. Insurance companies do 'shop' providers.

[greenG4]

In short...there is no conspiracy to nickel and dime you to death. It may seem that way, but the health care industry is not seeking to find new innovative methods of getting money from their patients. Quite the opposite. Every healthcare facility I have ever seen is actively doing what they can to decrease their and the patient's costs. This includes constantly adapting Quality Assurance (QA) programs, investing in HIT products, enumerable cost-benefit analyses, etc. And this is even true of health insurance companies. That's why health insurance companies strongly encourage (some require) annual physicals, etc. They know that regular screens are vital for preventative health. This helps both the insurance company and you.

(And yes, you could take fingernail clippers and remove the stitches yourself, but if you get a Methicillin Resistant Staph aureus infection, don't expect to be able to sue. )

[CRASH HARDDRIVE]

Originally Posted by Uncle Skeleton 

Why can't patients do this themselves at home?

I would guess many people still do.

When I was a kid, I remember my parents telling me pretty much the same thing this doctor said-a piece of glass I had in my foot (don't remember how it got there) would come out on it's own. I also remember my mother pulling a piece of glass out of my foot with a pair of tweezers, sterilizing the wound, and stitching me up with a needle and thread. I'm sure it may have hurt a little, but I honestly don't recall, so I guess it's safe to say I didn't suffer any trauma or permanent damage. I do know it didn't cost anyone $80.

[greenG4]

Originally Posted by CRASH HARDDRIVE 

I would guess many people still do.

When I was a kid, I remember my parents telling me pretty much the same thing this doctor said-a piece of glass I had in my foot (don't remember how it got there) would come out on it's own. I also remember my mother pulling a piece of glass out of my foot with a pair of tweezers, sterilizing the wound, and stitching me up with a needle and thread. I'm sure it may have hurt a little, but I honestly don't recall, so I guess it's safe to say I didn't suffer any trauma or permanent damage. I do know it didn't cost anyone $80.

You bring up a good point. There are a lot of minor things that people now go to the ER or an Urgent Care Center for when in previous years they never (or rarely) did. But that's a choice we make ourselves. IF it's worth the peace of mind (or whatever) to pay $80 then so be it. If not, then for something so minor, do it yourself.

[medicineman]

You can remove your own stitches, as long as you know what you're doing. There are 3 or 4 stitching patterns that are used. A doc can look and tell IF this is the right time to remove them, or partially remove them. He can tell if he exudate is clean or infected. As with anything else, you're paying for someone's expertise.

You can stop your dripping faucet for a $4.50 stem replacement, or call a plumber and it'll cost you more than $80.

[Uncle Skeleton]

What I'm hinting at is that maybe this grand disaster that is the current health care system ought to be blamed more on whiney "helpless" patients than on the system falling short. After all, humans managed to survive quite a while before health insurance was invented. Sure, our expectations of health are higher now than in centuries past, but so is our capability to spread information and help/teach ourselves. What doctors do isn't magic.

[ink]

Originally Posted by Railroader 

Your experience is EXACTLY the opposite of mine. I asked my doctor what he would charge me if I paid cash for his services instead of going through insurance companies and he quoted me a price nearly 50% of what he charges the insurance company. He stated that he would save a lot of hassle collecting from the ins. co. and would have more time for patients.

My wife is an oncology nurse. She used to work for a very small practice with only two physicians, and she had to handle some of the accounting there as well. She concurs with Railroader; when insurance companies weren't involved, the doctors charged less. When insurance companies were involved, they would go right up to the maximum that they could get from them. They would turn around and do free service for people who didn't qualify for Medicaid and still had no health insurance (post-adolecent folks with craptastic jobs).

[ink]

Originally Posted by CRASH HARDDRIVE 

When I was a kid, I remember my parents telling me pretty much the same thing this doctor said-a piece of glass I had in my foot (don't remember how it got there) would come out on it's own.

Be careful with this advice...

My mom had blinding pains in her leg when I was about 10. She went in, and it turns out that a piece of glass that she had stepped on years previous had worked its way up into her leg. She had to have general-anesthesia-surgery to get it out, and was in the hospital for a few days.

[Eug]

1) Some have argued that small user fees (co-pay) don't stop the abusers. What it does do is turn away some of those who might actually need the care. Those who aren't usual users of the medical system are even less likely to go to emerg if there is an extra up front free. However, those who habitually abuse the system are often happy to pay the small extra up front fees.

2) It's strange that anyone would claim that glass lodged in a foot would necessarily eventually work its way out on its own. It's just as likely to stay there forever, or else get seriously infected.

[CRASH HARDDRIVE]

Originally Posted by ink 

Be careful with this advice...

My mom had blinding pains in her leg when I was about 10. She went in, and it turns out that a piece of glass that she had stepped on years previous had worked its way up into her leg. She had to have general-anesthesia-surgery to get it out, and was in the hospital for a few days.

Ouch.

Kind of amazing that process took years.

I should clarify my post wasn't really advice, (I'm certainly no medical expert) just another anecdote, and one that I'd imagine was fairly typical.