Dollars and Senseless

IMG_3774

People in the US are used to this sort of thing but I wanted give everyone a peek into the way healthcare is billed:

The price charged to insurance for OR use and three days of babysitting for a ruptured appendix was $42,500.  No ICU. This does not include the surgeon’s fee or the anesthesiologist’s bill or the pathologist’s examinationof the removed offending organ.

The amount actually paid by insurance was $8,950 with an additional $680 of patient responsibility (what the patient has to pay). 

The other over $30,000 was “adjustment”, money that will never be paid by anyone. 

The games we play. 

After the birth of my child, I received a bill from the hospital for my care… over $2,000. There were also bills for the OB, anesthesia, pediatrician, the NICU stay, etc. 

I expected the bills to be high. My baby was worth any price but I still wanted to know what my money was paying for. Being on the physician side of medicine, I don’t often get to see the $ side from the standpoint of a patient so I decided to dig.

What I found most annoying was that the bill was not broken down into anything meaningful, so I requested an itemized bill so I could see the details.

When I reviewed the several pages of information that came a few weeks later, I found several charges for questionable lab tests as well as medications that I was fairly certain I had never received. Propofol, a sedation medication commonly used in ICU… the one that killed Micheal Jackson. Dopamine, a vasopressor that is used in the ICU to keep your blood pressure up. There were a couple of obscure infectious disease tests that there was no reason for me to be tested for. I called the billing number and listed my concerns to the woman who answered.

“So are you requesting a review of the charges?” She sounded astonished.

“Yes. Yes, I am.”

A week or two passed and I received a call that said that over $700 of the charges had been removed but there were still two items that I was disputing, the lab tests that should have never been done, that they were not going to budge on.

“Well, I would like to see proof that they were done and I would like to know why because they do not make any kind of sense.”

“I cannot provide that.”

“Then I would like to request a copy of my records.”

“Ma’am you are more than welcome to request a copy of your medical record. The charge is $4 per page.”

“How big is my record?” 

“I don’t know but I expect probably over 40 pages.”

(Was it really $4/page? Maybe it was less. Were there only 40 pages to the record? Probably there was more. Much more. It was a few years ago, and I don’t remember the details exactly but suffice it to say, the cost was going to be quite high.)

“Can I come by and just review my record?”

“Absolutely not.”

I did some quick math and figured that the disputed charges were less than the cost of the copy of my medical records and I ended up just paying the dang bill as it was.

Fun, huh?

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Needled 

Door of St. Patrick's Cathedral in New York City

“Your mammogram shows an area the radiologist is recommending that we biopsy. I am going to put in a referral for you to see a breast specialist to get that done.”

“Um. I already have the biopsy scheduled. The radiologist said they could do it. It has been approved by my insurance and everything.”

I glanced at the time stamp on the mammogram report. She’d had the mammogram done just that morning. The report summary said “suspicious calcifications concerning for malignancy….”

“I would really rather we get you hooked up with a breast specialist to do this.” 

Silence.

Who do they think they are, scheduling my patients for procedures that I have not even authorized yet?

“I’d rather just get it done. It’s already scheduled for next week.”

“Look, I can get you in with the specialist in just a few days. This is not going to delay care in any way.”

Suspicion began to creep into her voice. “I really don’t want to,” she said firmly. What exactly had they said to her? 

How do you say, “I think you might have cancer,” without causing panic? How do you remain professional when you are seething inside?

If it were me, if it were my mother, I would want to have the biopsy done by a breast specialist, not a radiologist. They have surgical training but more importantly, they know what to do if god-forbid-it-turns-out-to-be-cancer. Instead of waiting to see someone that can take the next step, I would be already plugged in. I have seen it too often. The panic, fear… the rage… 

My patients deserve the same care I would get, the same care I would demand for my loved ones.

I knew how it was going to go, though:

“If you don’t stop doing this, I am going to stop sending my patients there for mammograms.”

The manager laughed at me through the phone. “You have to send patients to our facilities. We are in the same system. You know they track that sort of thing.” 

And she’s right….

The suit squinted at me from across the table.

“So, in analyzing the data from your mammogram referrals we see that you are sending about 52% of your patients to outside facilities. Care to elaborate on why that is?”

“Is it required that I send patients to only system facilities?”

“Oh, no. No. It’s not required.” 

That would be illegal.

“So why are you here talking to me about this again?” I could feel the pricks of anger rising under my skin.

“We can’t require you to do that but in the interest of managing costs for patients…” He trailed off. 

In the interest of keeping more money in the system…

I held back a laugh. 

It was an interesting thing, how much more frequently my patients getting mammos at system facilities seemed to end up getting biopsies compared to those facilities outside the system that did not do biopsies as part of their services. Did they track that, I wondered? Was my perception about this correct or merely a projection, tainted by the animosity I felt? I resolved to start keeping a tally.

“While we are on the subject, your referrals to system specialists is below the system average for primary care. Why?”

“The why depends on the patient. Some prefer to stay in the area. Driving downtown is a hardship for a lot of them, not to mention the cost of parking. Some need a physician with a certain set of skills or a certain personality. Some have experience with a physician through a family member or have been seeing this specialist for years and need a referral each year because of their insurance.” 

Why am I justifying this to you?

A month ago they added a button on external referral orders that requires me to provide an excuse so they can better track such things. If there was a “bite me” option on the choice list, I would use that. 

Previously they had only loaded the contact info for physicians within the system. If they were not a system specialist they had to be loaded manually by filling out a form that went to the practice manager then to a practice administrator and then to a VP and then to someone to add them in. It took weeks.

Provide us with a list of the specialists you would like to use and we will contact them to try to get them to join the system.”

“I’m not doing that. I’m not letting you use my name to convince them to join anything. If they want to join, they can look you up. Meanwhile, I will continue to refer in a way that keeps the best interests of my patients as a priority.”

Technically they could pull those names from electronic health record. Maybe they already had.

“Oh, we always want you to keep the interests of your patients as a priority. We would never ask you to do otherwise.”

Except that is not how it feels…

Thursday Thoughts From The Throne #3

Black and white Gerber daisies

The nice thing about your loved one continuing to ignore your advice about going to the ER for their severe right lower quadrant abdominal pain until their appendix eventually ruptures is that in a few weeks when it is clear they will live and the post op pain subsides (you have to be nice to them until then) you will have ammunition to use for the rest of their life… if you are the kind of person who does that sort of thing.

*wink*

Helping Yourself

Angel at the Met in NYC

“We are going to bring meals for the next week or two if that is OK. People really want to help out in some way.”

I sat staring at the email and struggled with an answer. 

Asking for help is hard. 

Receiving unsolicited help gracefully is even harder. 

Why?

I don’t need help. I don’t want help. No, that’s not true. I don’t want to need help. I feel guilty needing help. I feel guilty receiving help. 

What will other people think? I’m a doctor. I could just order stuff, right? I have a money cushion that a lot of others don’t have. Will I be judged for accepting help? Moooching. Weak. Will I then owe people favors that they will call in later? I don’t want to OWE anyone anything.

To accept a meal, you have to be decently dressed and willing to socialize for a few minutes. Are we going to look sick enough? Needy enough?

The first meal was a chicken pot pie, caesar salad, and lemonade pie. It was amazing. It was helpful. I needed it. I was grateful. We subsisted on left overs for a few days.

“We will be dropping off some restaurant gift cards…”

You know what else I needed help with? Buying groceries. It wasn’t about the money. It was about the TIME. How to get time to shop for the family while running back and forth between the hospital, home, school, job. Someone even volunteered to help with that.

Laundry. OMG, the laundry.

The house was a mess. 

Please don’t ask to come in. I don’t want anyone to see us living like this.

Sometimes others NEED to help. Not for me. For them. That was how I justified it to myself, but standing now on the other side I can finally admit that I needed it. I needed the help to keep my kids fed. To survive.

It took a lot of pride swallowing. Humility. Grace. Pushy people. Help. 

But we survived.

Could I have done it by myself? Maybe. But it was a helluva lot easier this way.

I think about those who don’t have that kind of support. Someone who is alone and ends up in the hospital and they don’t even know who will feed their dog or water their plants. I ache for those people now, in a way I have not before because now I understand. 

Not everyone has someone. 

Truthfully, I have always been someone who would say, “Let me know if you need anything,” and just left it at that. It’s what you are supposed to say, isn’t it? Secretly I would hope they didn’t need anything. 

Where would I find the time to help? Surely there are others who will step up. It doesn’t need to be me, does it?

From now on I will be one of the pushy people. I will offer to grocery shop or do laundry or provide a meal… something specific. 

And I will be one of the pushy ones.

Stretched

Dinosaurs in the American Museum of Natural History

“I want to change doctors.”

Reviewing her chart before entering the room I could see that she had been asking for this for months. The medical assistant had warned me that she was going to bring it up again.

“Why?”

“Well, I never get to see her when I need to. She’s always out or I have to see the nurse practitioner because she’s too busy. Besides, you were the one recommended to me by several coworkers but you weren’t taking new patients.” She stared at me, accusation in her voice. 

“Well, the reason I stopped taking new patients is because the ones that I did have could not get in to see me when they needed it.”

Some days I have open slots that don’t fill. It makes me antsy but I try to remind myself that not overloading the schedule ensures that people can get in if they need to. I want to be able to see them, have a relationship with them, even if it hurts my bottom line. THAT gives me joy.

“….But you should also know that I have kids. Sometimes they get sick. Or I get sick. Or some other emergency pops up…”

“Well, she doesn’t have kids. At least not that I know of.”

In truth she is undergoing a fertility work up, hoping to have kids but it was not my place to tell a patient this without her permission. A woman should have the right to have a child if she wants one, shouldn’t she, even if it inconveniences others.

I agree to take her on as a patient. The very next day:

“Uh, mom?”

“Yes?”

“I just puked.”

The smell of vomit began to waft through the car. I cracked a window.

“Block my open slots until I can get to the clinic and see what is going on.”

“You don’t HAVE any open slots.”

As my daughter retches again into the plastic sack I know I don’t have a choice. They will all have to be rescheduled. There is no one else that can watch her.

“He’s going to have surgery. I’ll need to be out for at least a week….” 

It makes me nauseated to think about it, rescheduling that many people, but it just cannot be helped. 

He needs me.

No doubt someone, somewhere is asking to change doctors. Knowing that bothers me on some level but being a mom also brings me joy. My kids deserve a mom who can be present for them. It strikes me that this sort of issue is unique to female physicians. It is partly why we make less money. It is partly why we don’t hold as many leadership positions as our male counterparts. 

I choose my kids. 

I choose my family.

Meanwhile, I am sitting in a hospital room with my laptop, trying to do as much as I possibly can from here.

That doesn’t make me better. Or worse. Just different. 

Or maybe the just same. 

Past Pains

Ruins of the Ellis Island Hospital

A deafening shriek reverberated again off of the tiled walls and metal tables, the sound of pain and fear made all the more palpable as it echoed around the cold, hard surfaces and magnified until it shook the very core of anyone listening. 

The staff inside that room did not make eye contact with each other over their masks. To acknowledge anyone’s humanity, even their own, would only serve to distract from the task at hand.

*****************************************

This is another shot from inside the ruins of the Ellis Island hospital. Several areas contain art by JR, a French artist. Generally speaking, I prefer my ruins untouched but this image seemed to enhance the spooky feel rather than detract from it.

It is disconcerting to stand in the empty rooms and corridors imagining the hustle and bustle of a busy hospital. There are times you can almost feel the brush of someone passing or hear the echoes of fear and hope whispering off of the crumbling walls. 

I ran into some photos of the hospital taken in areas that I did not get to see when I was there and it makes me want to go back, to somehow have more access. I wonder what that would take? 

Have you ever felt drawn to a place in a way you cannot explain? 


Dread 

Morgue at Ellis Island hospital

I dread going back to work after being off for a vacation, even if it was only for a few days. 

I know, I know. I’m not alone, am I? 

The thing is, I never know what my in basket is going to look like. After a regular weekend I can walk in to find 50-70 items on my virtual EHR (electronic health record) desktop. After a week of vacation it may be 150 or more. 

Please God, let it be manageable!!!!

When one of my partners is off, it is a full on life/death struggle to keep my head above water and I am certain they have experienced the same frantic craziness trying to keep up with my stuff while I’m out. 

Patients get crabby when their physician is gone and there will invariably be several fires to put out. Did the clinic roof leak again? Did my office manager actually reschedule the patients that I saw were on my schedule last Monday? Did that woman’s MRI get done? What did it show? 

It was not enough that I worried about everything all week. Oh, no. Now I have to face up to it in the morning.

Gah.

I won’t be sleeping well tonight.

*****************************************

The photo above is what is left of the morgue inside the ruins of the hospital on Ellis Island. It was a teaching hospital so autopsies were done in this theater. On the left is where the bodies where stored. I took the hard hat tour and got some really great images. I wish I could have gotten to see some of the upper floors, like where the ORs were. Maybe someday…. 

Take Me Higher

Entrance to St. Peter's Basilica at the Vatican.
The young woman glanced down at the distinguished, gray haired gentleman propped up on pillows as she hung the bag of potassium from the IV pole at the head of the bed. 

He was more handsome in person than he appeared on TV, she decided.

“This might burn going in,” she murmured. “The computer says your level was a smidge too low.” They were piloting a new AI program that made treatment decisions instead of doctors. It was said to be more effective and more reliable, better outcomes.

The patient looked up at her from his newspaper and nodded, winking. “Thanks for the heads up.” A great wracking cough rattled through his chest at that moment, leaving him gasping for breath. He sat down the paper. There was his face on the front page in an article talking about his admission to this very hospital for pneumonia.

“That sounds… better?” It was a statement and a question. She looked at him hopefully.

“Oh, believe me, I do feel better than I did yesterday.” He spit out the great glob of yellow phlegm that had caught in his throat, then wiped his mouth.

“On the mend, then!” She smiled down at her VIP patient. Her shift was approaching its end and she felt some degree of melancholia about that. Rubbing elbows with the rich and famous was quite fun.

Illness was the great leveler, after all.

She couldn’t wait to tell her fiancé! 

And her mom. 

And her best friend. 

Technically she was not supposed to tell anyone about this fellow, privacy laws and all that, but how could she be expected to keep a secret like this? She had really met him, spoken to him, touched him. The part she would not tell anyone about was the number in her pocket. He had slipped it to her after telling her she was beautiful and that he would like to hook up sometime. She patted her scrubs absently to make sure the paper was still there. Not that she would ever take him up on it, mind you.

Power was sexy…. but phlegm? Not so much.

She walked out of the room and back to the nurses station where she charted her activities of the past hour or so in the EHR. She caught sight of the man’s wife getting off an elevator and she found herself watching with envy. The woman was beautiful in a way she herself could never hope to be. His wife walked purposefully, a blue coat draped elegantly over her arm, a slight smile curled on her lips. No one at the hospital had ever seen her smile before. They were all warned to stay out of her way.

He must have called to tell her he was feeling better.

The nurse glanced back at the computer screen. There was a new order for another six bags of potassium for the fellow in room 432. 

How odd.

A quick check of the blood test results reassured her. His potassium level was indeed very low.

She checked her watch. It would be another 30 minutes before she could hang the next one. The next shift would be kept busy, that was for sure.

*********************************

The papers and news stations all shouted about his death. Across every front page. Leading every news program.

He was dead.

She couldn’t believe it. How? He was getting better.

Then fear. 

Did she do something wrong?

*********************************

The voice on the other line spoke a greeting in Russian. 

“It is done?” she asked.

“Da,” the voice said gruffly then hung up.

She smiled to herself as she dropped the burner phone into the crackling fire and poured herself a glass of champagne.

Yes. Of course it was done. A simple hacking right under their noses and no one would ever know. Cardiac arrest from a potassium overdose. In the hospital. They would do everything possible to keep it hidden if it were discovered. No one wants to be the hospital that killed someone like him…

It was a beautiful, elegant thing.

There would be no other women. 

Veracity


He chuckled to himself. Potassium level?

Let’s make this one 6.5….

He hit enter then scanned down the list. 

Ahhh… a 90 year old woman. Perfect!

This time he picked the sodium level. 

126

In thirty minutes he had changed the results on over three dozen patients. Just one or two per provider, not enough to cause much of a stir…. Since none of the docs at the various system clinics spoke to each other.

*******************************

Potassium level 6.5? No eveidence of hemolysis noted. Damn.

She sighed and dialed the patient’s number, hoping he would pick up.

“Hello?” a male voice said

“Mr. James?”

“That’s me…”

“This is Dr. Stephens. I was calling to discuss your lab results. Do you have a second?”

“Sure, Doc!”

“Your potassium is showing as rather elevated. Most of the time this ends up being an error but at this level, if it is true, it can kill you. We need to get it rechecked. The best place to do that is the ER. They will recheck the levels and do an EKG and if it is really elevated they can bring it down.”

“Are you sure?”

“Yes, sir. I know going to the ER is not a cheap proposition but I don’t feel like at this level we have much of a choice.”

He sighed audibly. “Ok, Doc. If you say so. Should I go right now?”

“Yes. I’ll call ahead and let them know you are coming and why.”

She had alerted the lab to these abnormal results several times. Each and every time it seemed they were proven false. It had been occurring since the mandate that all providers had to use the system laboratory instead of sending their samples to an outside place. Invariably she was told it must be a problem with the way staff was drawing the blood. 

Only it wasn’t… She knew that was not possible.

*********************************

The board gave a standing ovation. Revenue for the system had reached an all time high. It had been a banner quarter. Things had been looking grim for so long….

A nondescript figure in a dark suit with a light blue silk tie sat silently in the corner, arms crossed, smiling to himself. 

The Cost of Protection

Carved flowers on a Victorian tombstone.
There have been several times over my career that I have had to step in to protect a patient from their family. Each and every time it gets nasty. It takes a certain kind of person to abuse their child or to molest a mentally challenged adult or neglect an elderly person to the point they have maggots in their wounds. Those kinds of people fight and they fight dirty.

I marvel at how some attorneys can look at the facts of a situation and defend it by attacking and terrorizing the physician who had to make the call. It is exhausting and terrifying and can leave you questioning yourself and your judgement throughout the process:

Surprise subpoenas summoning you to appear in court in 60 minutes, requiring you to cancel all of your afternoon clinic appointments at the last minute.

Threats of lawsuits.

Antagonist depositions. 

Lies and accusations made publically.  

Nothing in medical school prepares you for this sort of thing. Physicians have malpractice insurance but this is not malpractice. There is no one to walk you through it unless you hire your own expensive attorney.

Eventually you are vindicated but not before your life is made a holy living hell. It takes a toll on your family and friends as well, as you cannot discuss it with anyone else. The process can drag on for months or even years.

You are isolated and alone.

Fortunately, all of my experiences have been before social media. I have seen, of late, some unbelievably ugly online attacks made on physicians who are only doing their duty and trying to protect the vulnerable. It appalls me how quick the rest of the world is to jump onto the hate the doctor bandwagon when they do not know the whole story. Physicians are not allowed to defend themselves due to privacy laws. The rest of the world will never know the whole story.

What some people seem to forget is that our role as physicians is to assess the situation and make a recommendation. We are required by law to report suspected abuse. We are not omniscient super humans and maybe we don’t always get it right. All we can do is our best. In the end is up to the courts to decide guilt or innocence. 

The price we pay to do so is often very, very high….