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?

Advertisements

Biometrified

Stubborn
The tall, slim receptionist took my information and motioned for me to have a seat. “He’ll be with you in a moment,” she murmured sweetly. 

I settled myself into a nearby chair and pulled out my smart phone. Time to catch up on some blog reading. 

At one point I looked up from a post and saw the woman take a bite of a candy bar. She turned to a coworker standing next to her and whispered loudly, “My biometric screening appointment is in two weeks. I have to start my liquid diet tomorrow. I need that discount!” Her coworker mumbled something inaudibe in commiseration as she munched a largish chocolate chip cookie* then said, “There is no way I will ever have the right waist circumference. I just don’t even bother to try anymore.”

Is a liquid diet healthy when the rest of the year you eat like crap and don’t exercise? Apparently her employer thinks so. 

Many employers appear to think so.

I have serious issues with companies who discount insurance plans based on whether or not an employee falls within an assigned range on their blood sugar, cholesterol, BMI, and blood pressure. Does it really improve health? I am skeptical. 

High cholesterol effects, blood pressure issues, diabetes complications… generally are not going to cause an increase in health expenditures until much later, presumably when patients are retired or no longer employed. So why would their employer care now? Between the two of us, it smacks of a way to force employees to pay for more of their own insurance costs. I wonder how much that saves corporate America? 

So sorry, that’ll be an extra $600 in our pocket. Better luck next time!

It isn’t just that I hate taking the time to fill out the forms for patients, though they are tedious. It feels like a terrible invasion of privacy. Why does an employer need to know if your blood sugar is under 100? What difference does a 102 make to whether or not you can do your job? What does a 102 mean for absenteeism, productivity, customer satisfaction, or anything else they want to measure?

“My employer seems to really care about my health. They gave me a free pedometer!”

“Has that made you walk more?”

“Well, no…”

Each program, it seems, has its own unique set of thresholds… some want a blood pressure under 140/90. Some want a blood pressure of 130/70 or less. Some want a BMI of 25 or less. Others want a BMI of under 30 or even 35. Some don’t care about where you fall, they just want you to submit the numbers. Others want you to enroll in an online health class or two. I have never had a patient come in, however, and tell me that they saw the light after one of those classes and have decided to change their ways.

Many companies require employees to go to a screening at HR rather than heading to their own physician. They have a lay person interpreting those results and giving suspect advice to my patients that can take several office visits to undo. Worse, many patients then believe they then don’t need to do a physical with their primary care physician. I lose my one opportunity each year to catch patients up on their PAPs and mammos and colonoscopies, my one opportunity to screen for depression and to talk about healthy lifestyle.

Here’s another thing, though. There are people who have “high” cholesterol who are in great physical condition otherwise and yet, because their LDL is above a certain point, have to pay considerably more for their health insurance. What difference does an LDL of 148 make when the HDL is terrific and there are no other risk factors for cardiovascular disease? I wouldn’t be putting a healthy 24 year old patient on a statin drug because their LDL is 130 simply to get them below 120 for a better insurance rate. And then there is the issue of diabetes. It is a false perception that diabetes is only about diet and lifestyle. It is a genetic predisposition. Is it fair to punish you because your diabetic parents decided to have children? Ultimately it is a form of genetic profiling and I am surprised no one has made a bigger issue of this. 

We have a version of this for employees of the healthcare system I work for. There are tons of invasive questions about my daily habits and diet and exercise routines that I am required to answer and then I have to submit my screening numbers and measurements electronically to HR in order to receive the discount. We don’t have to meet certain criteria on those numbers… yet. I choose to opt out. I have the financial luxury of being able to do that, paying more for my health insurance. Many people, though, don’t have that ability.

So what are your thoughts?

*Please note, I am not saying here that chocolate OR cookies are inherently evil. In fact, they can be part of a healthy diet.

Concierge 

Gerber Daisies

“The letter said I had to pay $2400 each year to remain a patient because from now on he was going to be running a concierge practice. I would still have to use my insurance and pay deductibles and such. He’s a good doctor but I just don’t have that kind of money!” She said it in a way that made it clear the she hoped he would not hold it against her that she would have to find a new doctor. It wasn’t his fault. It was hers…

Trust me, honey, I know him. He doesn’t give a rat’s ass.

I get told all the time that I ought to go into concierge practice. 

But I won’t. 

Not ever. 

The fact is, I would feel like such a sellout, I wouldn’t be able to live with myself.

Why do I hate concierge medicine so much? 

I want to believe that it is because I think healthcare should be equally good for everyone, not better for those who can pay more. Concierge medicine smacks of elitism. Maybe, though, it is because I don’t understand people that have that kind of money, that kind of entitlement. Yes, I have assigned an unfair stereotype, haven’t I? 

Maybe I am simply jealous of them?

And then I wonder at what point do I actually become one of those rich, entitled people? Is it when I become willing to pay the retainer fee? Or some point before? 

Do I have to have gobs of money to be one of them?

Is wearing a large chunk of fake diamond on my finger selling out, too, in a way? I have had it for just over a year now. People treat me very differently when they notice the “rock” on my finger and I have to admit that I like it, I like the deference and I feel dirty because I like it. And then I ask myself WHY does that make me feel dirty and not any number of other things from my checkered past? 

And so I come back to some level of jealousy. 

I am not noble. I am eaten up with jealousy and having to face that every day would be painfully difficult.

That is why I cannot do concierge medicine. 

Shopping Around

Macy's in New York City

“She doesn’t have physical exam coverage and her insurance only allows three office visits per year. No lab coverage. No preventive care coverage. She needs her blood pressure and diabetes meds refilled but she cannot come in for a physical.”

I’ve seen this a lot lately.

“No problem. Tell her to come in for a regular office visit so we can at least check her blood pressure. I will code a 99214 and she may get a 30% discount off that as a cash pay patient. I can send her to a discount laboratory for labs that will save her hundreds of dollars. In October she can get a $99 mammogram at one of the local imaging centers. Her flu vaccination she can get cheap at the health department. We will just have to postpone her PAP another year.”

So she came in….

Crying.

“I pay over $700 a month for this insurance.  I work for myself and with my diabetes no one will cover me otherwise. I can’t afford anything else. They told me that all of my doctors were covered and my meds were covered. They lied.”

She did not read the fine print. Not that she really had any other options available to her… 

It used to be like this ten years ago. People with expensive but essentially useless policies. Here we go again. Now, at least, I have access to a discount laboratory. 

OMG. What A Day….

Some days are just…. just a crazy mad dash to the finish line. I am exhausted but I promised one of my most favorite people in the whole world, Craig Boyack, that I would invite him over to talk about his new book The Enhanced League.

I’ll let him tell you all about it while I draw myself a nice warm bath and soak my weary body in some lavender bubbles. 

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

Thanks for inviting me over today to talk about my newest book, The Enhanced League. This one is a little different than anything I’ve released before, and I’m kind of excited about it.

One short story, called The Enhanced League, was on my list when I wrote my second Experimental Notebook. I wrote it and intended to include it in that book. It had a nice twist ending, and almost a Twilight Zone feel about it.
The story wouldn’t leave me alone. When I assembled the Notebook, I left this one out and placed it in a new folder. I knew The Enhanced League had more to offer than just this story. I started making a new list of story ideas about one year in the professional baseball league where almost anything goes.

One day, while commuting to my paycheck job, I was listening to MLB Radio on Sirius-XM. They had a kind of spoken word anthem, narrated by Tommy Lasorda. If you’ve followed baseball much, Tommy is one of the legends and he has a distinctive voice. If I told a baseball fan to read the rest of this post in Tommy’s voice, it would immediately come through like that.

The piece was wonderful, but MLB Radio chopped it into sections with broadcast highlights. I wish they’d left it alone. I heard it a few more times, but never without the interruptions. This attracted my Muse, and I decided to do something on my own.

I sat down and wrote out a baseball anthem in a kind of second person point of view, just like Tommy’s. I liked it, and decided to keep writing them. Then it occurred to me that the broadcast interruptions were a kind of message to me.

The broadcast interruptions were intended to enhance Lasorda’s spoken word poetry. I don’t know what it was, so I’m calling it an anthem, and I called mine anthems too.

After I wrote the first one it became easier. My own imaginary Tommy Lasorda just wandered in, took a seat on the couch, and started talking. All I had to do was write down what he said.

My blog followers and regular readers know I’m always up for something new. These anthems were fun, and I think they enhance The Enhanced League. I peppered them throughout the book, and think they really add some fun human elements to the story. I hope you enjoy them too.

Oh, and I still can’t read one without hearing it in Tommy Lasorda’s voice.

***

cover

Blurb: The Enhanced league is a collection of short stories and anthems centered around a year in a fictional baseball league. It has a slight science fiction background. This league has a lot more pomp than you might be used to, and nobody seems to care if the players use performance enhancing drugs.

Stories involve existing heroes, up and comers, and falling stars. While there are the obvious stories that take place on the field of play, there are also human interest stories that take place around the baseball gyrations. These stories involve scouting, trades, ruthless business decisions, and even relationships.

I enjoyed researching and bringing you The Enhanced League, and I hope you enjoy it as much as I did. — CB

Click here to purchase!

boyack
I was born in a town called Elko, Nevada. I like to tell everyone I was born in a small town in the 1940s. I’m not quite that old, but Elko has always been a little behind the times. This gives me a unique perspective of earlier times, and other ways of getting by. Some of this bleeds through into my fiction.

I moved to Idaho right after the turn of the century, and never looked back. My writing career was born here, with access to other writers and critique groups I jumped in with both feet.

I like to write about things that have something unusual. My works are in the realm of science fiction, paranormal, and fantasy. The goal is to entertain you for a few hours. I hope you enjoy the ride.

Craig

Blog My Novels Twitter Goodreads Facebook Pinterest

Cash Flow

Fountain at the Alamo in San Antonio

“You tell that doctor to write me a prescription for something affordable!”

*Click*

My medical assistant glanced up at me with a shocked look on her face. There was no need to repeat the conversation. I had heard every word.

“That does not make any kind of sense. It is a generic medication. It should only cost $40. Max. Call his pharmacy and find out what that med is going to cost him there.”

Later in the day I read the computer message that said it was going to cost $340 for a one month supply. Hell. I wouldn’t even pay that. 

I typed out a quick message and routed it back, asking why it was going to cost that much.

It is the brand name. If you want them to fill the generic you have to write for the generic. 

Except that I HAD written for the generic. I always write for generic. 

I sent back a stongly worded message pointing this out and telling them to fill the frickin’ generic. 

This was followed by a string of other patients with similar complaints all from the same pharmacy chain. Insurance companies refusing to cover prescriptions that patients had been getting without issue because the pharmacy chain was filling brand name instead of the generic option. It makes them more money. I would have never known this was occurring if the insurance companies had not denied coverage. 

From a drug coverage standpoint we love to hate on insurance companies but pharmaceutical company and pharmacy shenanigans are one of the reasons healthcare costs in the US are skyrocketing out of control. 

So I tell patients to be aware of what they and their insurance companies are paying for. If there are significant changes, please ask questions. Shop around to other pharmacies. The variability of cost from one pharmacy chain to the other is astonishing. AND, talk to your doctor. The only way I find out about these kinds of things is from patient complaints.

Just maybe don’t yell at my staff… 

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. 

Impact: Chapter Seven

Chicago in lights

“Next.” 

I stepped forward to the granite counter top and managed a weak smile. The woman in the bank’s uniform half-smiled back at me. Her striped blue and red scarf was tied jauntily at her neck.

Like a flight attendant.

“How can I help you?” She sounded bored. In her mid fifties, the woman had amazing hair with just the right amount of wave and body. 

I felt the familiar envy. I stared at that hair, wishing my own head was not covered with the flat, lifeless, straight as a board hair I had been cursed with. It was a dull mousy brown until I started to dye it blonde. At least the blonde helped. Speaking of which, my roots were showing. I needed to make a hair appointment if I was going to have to start interviewing for jobs now.

Times of stress always left me to dwell on each of my own flaws. My thighs were probably going to come up next. Maybe the crows feet. I was getting old. I looked closely at the woman’s eyes. She had great skin, too. I focused on her chin looking for hairs. 

Please let there be whiskers. Please let there be whiskers.

Nope. Not a single one. 

Damn it.

“Ma’am?” Irritation was in her voice and any trace of smile had now left her face.

“Oh. Sorry.” I felt my cheeks flush. “I need to make a deposit.” 

I pulled the paper paycheck, my last paycheck, out of the envelope. “Wait. I forgot to sign it.” 

The woman raised an eyebrow and passed a ballpoint pen to me. It was attached to the counter by a chain that made a slapping noise with each stroke. Banks were always disconcerting… unearthly quiet despite the hard surfaces and volumes of people. I felt I was disturbing the peace just by scribbling my name.

I passed the signed check to the woman. Her name tag read Elyse.

She waited, expectantly. “Where’s your deposit slip?” She looked at me, incredulous.

It had been too long since I had manually deposited anything into my bank account. My checks had always been deposited electronically. 

“Um, I don’t have one.”

“What’s your account number?” I could tell she was holding back the disdain with great effort.

“You know what? I don’t know that either. I have my bank card, though. Can you pull it up from that?”

I pulled the card out of my keychain wallet and handed it over.

“Do you have some ID?”

I cringed self consciously as I showed her my awful driver’s license picture. It was from before the blonde. She nodded, handing it back, and I tucked it quickly into the safety of my billfold.

Curt typing ensued. Then a scowl at the screen. More typing. Finally, she looked up at me suspiciously. 

“It says here that you closed out that account yesterday.”

A wave of nausea came over me.

“What do you mean?”

“I mean that it says you were here yesterday and closed out the account.”

There was $20,000 in that account.

“Does it say if I took that money in check or cash?”

She manipulated her computer mouse and clicked twice.

“Cash.”

There was no way to trace it.

“What about my savings account?”

“Also closed out.” 

I had scrimped and saved, trying to accumulate enough to eventually retire, hopefully sooner rather than later. I didn’t know how long I could keep up working as an ER physician. They had a high burnout rate after all.

It was gone. Every bit of it.

What was happening to me? Should I say something? Report it to the police? 

“That wasn’t me,” I said softly.

“Customers are not allowed to cash out accounts, particularly NOT accounts that large, without notice and without proper ID. I can assure you that you did indeed close out that account.”

“It was not me.”

A “Hmmmf…” of disbelief was all she uttered. The woman offered no other explanation, no further assistance. 

“Can I just cash this check, then?

“Fine,” she said sharply.

“In tens and twenties, please.”

I weighed my options as I watched her count out the bills, one by one. Four thousand dollars was not going to last me very long. Not in Chicago. 

Not anywhere, really.

At least I had paid the month’s rent last week. I was good there. 

The wad of bills was thick. I registered that my work computer was still there as I stashed them at the bottom of my bag. That could be helpful. I wondered how long it would take for them to realize I still had the thing.

I walked the few blocks back to my apartment mulling things over. Who could I call for help? I needed advice. Six months ago I would have called my boyfriend. Well. I would have if my phone had been working, but now, even if we were still on speaking terms I realized I did not know his phone number. I had never had to know it despite texting and calling him thousands of times over the years we had been together. My phone made communication with him a no-brainer. 

There had to be someone else I could call. Surely. As I rode the elevator up to my floor, I wracked my brain but there was no one. I had no friends. Only work acquaintances. There was no one I was close enough to that I could call them up and confess that my world was falling apart. No one except for him. Having regular sex with someone allowed you certain lifelong privileges didn’t it?

Probably not, but I still had to try. 

Maybe I could look him up on the work computer if my password hadn’t been shut down already. Not his cell number, of course, but I could Google his office number. He’d be in clinic right now if it was not a hospital week. If wifi was not working in my apartment, and something in the pit of my stomach told me it would not be, I could find a Starbucks somewhere… 

I turned my key in the lock. It stuck a bit and I panicked as I jiggled the key and retried it. Finally the lock clicked and I pushed open the door, relief flooding through me. 

My relief was short lived, however. It evaporated when I saw what was waiting for me inside. Or rather, what was not waiting for me.

Nothing

There was nothing at all inside. Every scrap of furniture was gone. Every last one of my possessions, gone. All that remained were the indentations in the carpet where my couch and chairs and other furniture had once been.

I was exposed. Bare. Naked. Nothing was left of me. At least nothing of the me that I once was.

My life was being dismantled before my very eyes.

It was time to fight back.

———————————-

Want to know how we got to this point? Check out the other chapters of Impact:

Chapter One

Chapter Two

Chapter Three

Chapter Four

Chapter Five

Chapter Six

Shooting Stars

img_4013

“The per patient expenditure for your assigned patient panel the last quarter was up by $XYZ, so we will be dropping your rating on our website from five to four stars. Your patient satisfaction and preventive care scores remain outstanding. We will re-evaluate your rating at next quarter.” A letter from one of the big insurance companies a few weeks ago.

You know what? Bite me. To my knowledge I am not wasting money. I take appropriate care of my patients.

But then it occurred to me, do patients even know that this is what those stars mean? How much money they and their physician cost the insurance company….

The Lost Dollars

img_2419

So there is this thing in the US that you may not have heard about. ACO’s, Accountable Care Organizations, are groups of physicians that have “joined together to provide high quality care” for Medicare patients. So says the CMS (Medicare) website.

What does this mean for patients?

Hell if I know. I don’t practice medicine any differently than I always have except that I find myself spending more and more of my time clicking the requisite buttons in the EHR (electronic health record) so patients get less of me. Quality care is quality care and should be given across the board to all patients no matter what bonus structure happens to be in place. I do have suits that come out and flash PowerPoint slides at me that tell how many of my patients ended up in the ER over the past quarter but I don’t pay attention. Frankly, I should not be making a decision whether or not a patient needs to go the ER based on what my “numbers” may or may not look like. 

What does that mean for physicians?

Supposedly, I get money every year that I can demonstrate that I provided savings to Medicare. If Medicare does not spend as much money but patients still get their colonoscopies and whatever else done (I have no idea how that is supposed to work), then I get a share of the “savings.”

How big is that check?

It is not like winning the lottery, that is for sure. I resent the insinuation that I need to be paid extra to do the right thing, but that is beside the point.

The healthcare corporation I work for requires me to complete some…. tasks… before I get this check.

For instance, I have to attend quarterly regional meetings and log onto two separate websites each and every month. To be honest, none of the physicians I know look at anything on those websites. They log on and log off to get the credit. (Of note, I have asked why it has to be two websites. Why can’t it just be one? No one gives me an answer.)

All of this, if it actually improved patient care, would be fine. But it doesn’t. Not one bit. It turns physicians into cute puppies doing silly tricks for their next treat and I refuse to participate. 

By not participating, however, the corporation gets to keep that check. I might not care about that if I knew it was going to go to helping indigent patients get access to care or some other noble cause but I don’t have the foggiest idea what they plan to do with it…

Personally, I think it should go back to Medicare.