Thursday, July 09, 2009

Insurance Anyone?

As most know, I recently broke my neck and was hospitalized for almost 2 continual months and had 3 subsequent stays for further care. Needless to say, the cost was more than any person could pay. How much you might well ask. I have NO FREAKIN' IDEA!!!

I'm reasonably well educated, despite having grown up reading by candlelight, but I can not make heads or tails of any insurance statements! And I'm a doctor?! +'s and -'s, benefits paid, deductible applied, insured's responsibility, etc All I can do is wait until the hospitals start complaining and then call and try to find out how much they expect from me. (Interestingly, hospitals are very easy to deal with and set up low monthly payments with no interest!)

Oh, and this is great, the insurance companies can actually take $$ back from hospitals that they have already paid if some pencil pushing "dr" beauro-cretin decides that a given treatment wasn't "medically necessary". One was to the tune of $52K!!!! I'm a doctor and I would have a treatment that wasn't "medically necessary"?!! PHUCK U!

And to top it all. This spring, on my insurance renewal date, the company was pleased to offer to continue my insurance for the mere sum of, get this, $2732 PER MONTH!!! I shit you not! I called to confirm and it WAS MONTHLY!!!

It's almost enuff to make me think a single payor system would be better. Maybe the savings in paper cost alone would help lower the national debt..


  1. No one is supposed to be able to understand it. That's part of how they make their money. You didn't think they were there to help *you* did you? Silly Doc. I'm glad you are well enough to deal with the bills and other nonsense.

  2. Don't you watch "Fox Sunday Housecall" with that Dr. Isadore Rosenfeld Quack on Sunday mornings... You can get a free "Traveler's Insurance Card" from the US embassy in the EU country of your choice...Just get yourself a cut rate non refundable airline ticket to wherever...I like the Harz Mountains in Northern Germany myself... and help yourself to that Free European healthcare...


  3. No matter how much it cost, you're worth it. You're one of a kind! (Thank God). Besides, it's probably just a lot of money since your hospital obviously charged by the foot. You can't realistically expect us "Davids" to pay the same as you "Goliaths".

    As for single payer (the euphemism for socialized medicine).... do you think that same level of service that was available to you will still be there under Demo-care? (I do not).

    Sure, the docs that you hadn't pissed off yet (if there were any) might have gone the extra mile, but would they be limited in what was available to them? Would you have been on a waiting list? Would the care have been available at all since you were a "hopeless" case for a while, and therefore you might have been considered a "waste of resources".

    No matter how difficult and complex the insurance aspect is to deal with, I'll take denial of payment over lack of ability to provide appropriate care any day.....even to your sorry butt!

  4. My son was in trauma for three days and it cost $70,000. Thank God for good insurance.

  5. Can somebody tell me why they pad the cost of materials on hospital statements, rather than be more honest about it and charge a fee to cover their unrecovered costs? I think it would be better if people saw where their money was actually going.

    For example, I got 17 stitches in my knee several years back. It was on a Sunday, so I went to the ER. (If I had known it was ok to call my doctor after hours for this and that it was cheaper, I certainly would have done so!)

    When I got the bill, I was hit by the sticker shock, so I requested an itemization. I was surprised to find that a pair of disposable surgical gloves cost $5.00 (These must cost a fraction of a cent to manufacture!). The gauze and other materials were likewise exhorbitant. But what is the point of jacking up the cost of materials when it would be easier to just tack a user fee on?

  6. oldfart,

    don't be such a curmudgeon. your hospital bill paid for 48 freeloaders to refill their lortabs or get fixed after their MVAs. selfish, selfish!

    what i don't understand is the insurance company's justification for your rate hike. your conditions were not known and they charged you "X". now your precipitating condition is fixed. how can they charge you "X plus what we paid divided by ten years/month?" isn't that the whole point of insurance? you pay in and usually don't need it but when you do the pooled risk of thousands makes your bill payable and they still turn a profit. is it even legal to do what they did?

    sorry to parade my naivetee in public, i understand auto premiums going up after a speeding ticket. got it. but health insurance? howz that?

    hugs to the family.

  7. DOn't you have employer based care?

    I would recommend you take a look at the Israeli health care system. Everyone must have health insurance; those who have limited incomes have their insurance paid by the state. THere are four plans to choose from and each much cover the same basic things. Israeli health care is very very good.

  8. I was hospitalized recently for a 2-day stay in a regular room of a crummy doctor-owned hospital for severe gastro-enteritis (high white count, 3.0 K+), and the cost was $25,000. My insurance paid $20,000 and the hospital came after me for the rest. I asked for an itemized bill, and found they billed me for 8 litres of IV fluids in 24 hours! There's no way they gave me 8 frickin' litres in 24 hours. Eventually they wrote off the balance.

    The doc who owns the hospital has said he bills for what is a fair market price for services (he hates insurance companies), but in so doing he gives Democrats the needed ammunition to demolish what's left of our healh care system. Brilliant (said with sarcasm).

    Why don't the Feds give everyone what they have...15 different policies to choose from? That ought to keep some healthy competition in the mix. The Feds (Senators, Congressmen) sure as heck aren't going to set their elitists butts in the waiting-room of one of those new Universal Health Care clinics.

  9. dear nightingale,
    au contraire, if you had gastroenteritis and were hospitalized for dehydration it is very likely that you did get 8 liters of IVF. otherwise i agree with you.

  10. PeggyU: It's a crazy markup. My brother-in-law sells medical supplies to hospitals and what they buy for pennies is priced to patients for dollars (a Tylenol or an Aspirin will cost you about $5 as well). The explanation is cost shifting.

    If you pay cash, you SHOULD get a big discount, but in fact, you get stuck with the highest bill since the insurance companies negotiate their prices down. Or as OF said, they just pay what they want to (ala Medicare) and you just have to take it since most states do not allow "balance billing".

    Certainly, some of it is making up for people who can't, won't, or don't pay their bill. But the hospitals also play amazing games with figures.

    By jacking the prices, they can offer bigger "discounts".

    In point of fact, it's so complex, that I've yet to find a CFO that has any knowledge of what most things in a hospital ACTUALLY cost. They know what the CHARGE is, but the cost is too complicated to know.

    For example, they'll tell you that a CT scan "costs" $800. But, the machine is already there. The CT tech is already there. Those are fixed costs whether they use it or not. They don't use film anymore (in most places), so there are no materials. A CT "costs" the electricity to run the machine. But they figure in the amortization of the cost of the machine; the maintenance of the machine; the costs of the computers to allow the radiologists to read the scans from beach in Cancun; the cost to repaint the room every year; etc.... Certainly, these costs have to be considered, but they cause the ACTUAL cost of a CT scan to vary depending on the number of scans done.

    It's a really complicated subject. When I worked in an HMO (never, never, never again) they were on our case about "spending too much money ordering tests on health plan patients". They always used the charges to try and make the point that we were "costing" them a fortune which was just not true.

    I once took my kid up to the ER to xray his finger. I set him in my office, had the xray taken, and brought my own splinting materials from home. I splinted him myself after I saw the xray. I got an ER bill in addition to a bill for the xray and the radiology bill (to tell me 2 days later what I had already seen and treated...thank you very much).

    When I refused to pay for anything but the xray, they tried everything they could to "justify" the charges. It was actually hysterical as they argued for why I had incurred the charges for sitting my kid in my office, bringing my own supplies, and doing the work myself! I finally won, by the way!

    Lisa, no we don't have mandated employer based health-care.

  11. 911DOC-
    I hear you, but I was up most of that first night; did not have a foley catheter to moniter such a alleged volume, and counted 3 litres. The second day I had 1 litre.

    They also did an CT of my chest, abd, and pelvis because they inadvertently found a mass in my chest on a KUB. Each area that was scanned cost $2000, not $800. Must be my zip code.

  12. My son had a head CT a few years ago, and the charge was $800. I don't know what the charges are now, but $2K seems excessive. The actual charge wasn't my point.

    You're right, people and hospitals like this give liberals the ammo they want to try and convince the public that the whole system needs an overhaul.

    As pointed out in Eto's post, they find these examples and paint the whole industry with this broad brush.

    During the election, we heard repeatedly about the 15 to 18% of Americans without health insurance. We heard horror stories (some were in fact quite unbelievable....literally). But I heard NOT ONE of the millions of success stories, of American medicine. The system needs refining and improving, but it doesn't need re-designing, and it doesn't need overhauling. That's just plain stupid.

    From your story, it seems like you got a lot of unnecessary stuff done, but try not to criticize other physicians without looking at a chart & talking to the doc, since lots of stuff becomes very clear when put into context.

    Unnecessary testing certainly does happen. I suppose that it could be to pad the bill if the person ordering the tests had a vested financial interest in the institution. I contend that most times "unnecessary" tests are ordered, it's to shield against litigation. Unless there is some form of tort reform, that isn't going away.

  13. I'm a hospital pharmacist & I can give you a bit of insight into why charges are what they are.

    There are very few "cost centers" in a hospital. Pharmacy is one, radiology, lab, materials management (includes central supply, disposable & reusable surgical equipment), etc. The cost centers can actually "bill".

    There are many areas of the hospital than cannot bill - all labor (this includes pharmacists as well as nursing, techs, aids, window washers, clerks, biling dept, executive dept, etc). But, all these people need to be paid somehow.

    The billing changed in the 70's to a fixed rate based on a diagnosis - the DRG. Prior to that, if you came in with a broken neck, the billing was for the OR time, lab & radiology , whatever meds (in those days it was a 30% markup, and a daily room rate (prorated in hours spent in ICU). If you had a complication such as an MI, that was treated & billed accordingly. Your daily room rate covered nursing, dietary & porters (the people who clean your room). Medication billing covered the cost of medication & labor involved (me) plus cost of overhead (in a hospital pharmacy it can often be more than 1M/month)

    After DRG billing came into effect (you can thank New Jersey - it started there), if you came in with a broken neck - the hospital got paid a flat rate. This rate was negotiated with each insurer, but they all became really close price-wise over time. There were years when some hospitals refused to accept some of the Blues since they tried to low-ball too far.

    So, all departments had to really find out what their costs are. I can tell you exactly what the pharmacy costs are to the penny during any given month. What I need to submit is a budget for those costs so the hospital can negotiate a price for each and every DRG.

    The price of a shot of morphine is billed as $20, but the cost is less than $1. But, I need to factor in all the pharmacists time, benefits, costs of keeping a certain amount of stock on hand at all times & that is just for my dept. Then the bean counters need to factor in all the costs of just keeping the hospital open - dietary, laundry, nursing, non-medical labor costs, heating, etc. They factor that into the "cost centers" budgets since we are billable areas.

    OldFart doesn't really see the actual amounts because his insurance has negotiated a price for his care. However, if he were a cash paying patient, that price would be much, much less.

    Its a complicated scenario & in my dept many drugs get bundled with other things - like pumps, IV solutions, etc. The contracts are wide ranging and interrelated with other depts.

    I hope this helps a bit in understanding billing in 2009. It was much easier in 1969!!

  14. You think thas bad. Try to get a cost estimate before a simple lab test. No one doc, hospital, or insurance can give the slight approximation. Thge basic thoery is give them your wallet and they will withdraw what ever they want and add bills to what they took.

  15. Farty, bite your tongue! Socialized medicine?? Commie care? Hell, they would have cut you loose rather than spend that much money. They will decide who lives and who dies. They will decide who gets care and who sucks stale Twinkie cream. They'll have no choice to ration because there will be so many people drinking at the government trough.

    I'm so grateful you had your insurance and got the best care available. We aren't done abusing you, yet, yanno...

  16. Where I come from, when a friend of an ER Doc is worried that he broke something, which, really, when you KNOW an ER Doc is much less then usual.

    The only thing he or she pays for is the Radiological cost, the ER Doc looks at it and says "Hrmm... should be fine, don't lift weights or do anything stressful"

    Or, "Oh, crap, ya broke it...oh well"

  17. Trying to figure out insurance gives me headaches (wonder if those would be paid for if I sought treatment). I know that every time I have surgery or any kind of testing done, we end up paying a lot more than I would expect considering the insane amount of money we pay each month for insurance.

    I am about to have more surgery and the bills from this one are going to be huge. At least I am expecting it to be since there is a gynecological oncologist assisting. I'm sure our insurance will consider at least part of whatever is done to be medically unnecessary as they did with every other surgery I have had. When I had thyroid cncer, my radioactive iodine was not covered even though my doctor said without it I was pretty much gauranteed that the cancer would come back.

    I have no idea how the insurance situation can be made better but the way it is right now (at least for me) is not working. I read somewhere that people are only a few medical crisis' (what the heck is the plural for that?) away from bankruptcy. For the past 4 years I have had one thing after another go wrong. I think for my family, it would be better if I had no insurance and "didn't have to pay". We do pay our bills, all of them and it really sucks.

    Oldfart, I feel your pain on this. It sucks that people who pay their bills are seemingly punished for that while people who don't can go about their business.

  18. Good explanation ano 1:22.

    You're absolutely correct that it actually made a lot more sense before the 1970's. I wonder what happened in the 1960's to complicate the picture so much?..............

  19. erdoc85 - DRGs - diagnosis related groups were an outcome of "boarding" patients or extended stay patients during the late 60s & early 70s. Do you recall admitting a surgical pt the night before surgery to do blood work, maintain NPO after midnight, etc? Also, we routinely kept cataracts for 4-5 days post op with 1 day at bedrest. We kept post-partums 5 days post delivery routinely as well. We also had a whole group of pts who were admitted on Dec 20 to rule out MI, bowel obstruction, clinical depression & stayed through the New Year. It was routine & a waste of medical resources. These folks had no where to go, so went to the hospital to mix with jolly working stiffs. Physicians were complicit in the arrangement. It was fee-for-service so they paid & we brough juice and propoxyphene.

    As good as it sounds, it was an attempt to reign in costs. It was conceived by Robert Fetter & John Devereaux from Yale with - you guessed it, support from the former Health Care Financing Organization(HCFA) now called Centers for Medicare & Medicaid Services (CMS).

    The goal was altruistic - it was designed to be homogenous units of hospital activity to which hospitals would have binding prices. The concept was this system would constrain the hospitals with money & require administrators to alter physician behavior. As an aside, it allowed tremendous data gathering to give information to physician practice patterns as well. Yes - as physicians, your practice patterns are watched - then and now!

    It began in New Jersey in 1980 with a few hospitals in New Jersey with surplus, breakeven & deficient budgets. It was tried in New Jersey for 3 years & in 1983 became nationwide. In 1991, the 10 top DRGs overall were normal newborn, vaginal delivery, heart failure, psychosis, neonate w/sig problems, angina pectoris, specific CV disorders, hip/knee replacements & pneumonia. These accounted for 30% of hospital discharges at the time.

    As of 2002, there are more than 900 DRGs - thus the whole coding issue. The BIG chang took place in Oct 2008 when CMS decided to implement Hospital Acquired Conditions (HCA) which are no longer considered complications if not on present admission (POA) - lets say OldFarts pneumonia or thrombophelebitis (I have no idea if he had these!). But, that allowed them to write them off as medically necessary - which I remember him saying they did.

    Sure - they were medically necessary for him as the patient, just not to be reimbursed by CMS. The thought process is those co-morbidities or complications should have been factored in and negotiated in the price. When its not, its written off - sucks for the hospital, but each year they learn a lesson.

    As I said - it really is more complicated than the old fee-for-service when your insurance paid 70% and you paid 30%. Try to get anyone to pay 30% of a neurosurgeons fee & I'll show you a screaming maniac. I get sh*t on a daily basis because someone complains they have a $35 co-pay on a drug that costs me $489 & would retail at approx $600.

    People have NO concept of the cost of what they incur when they have unlimited access medical care without knowledge of what the costs are & part of that has been our fault. We've allowed it with zero to $10 co-pays for physician visits, yet they don't understand why they need to wait to get authorization for a $1500 MRI.

    I have little patience! But, thanks for listening to a history lesson which might be boring to some, but really is the basis for where we are now.

  20. Ano 1:15. Very nice explanation of DRG's. No arguments.

    I was being facetious.

    I believe the genesis of the problem was in the 1960's with the institution of Medicare. This is when rules, bureaucracy, and red tape on a massive scale entered the payer side of medicine.

  21. With the right premiums such as everybody (from age 18 on) paying $60-$100 per month each, say, would raise enough to fund a good universal health plan.

    Put some force of law behind it - in Canada, your MSP (health plan) premiums can be deducted from your tax return if you don't pay them. There needs to be more pain from not paying your premium then the benefit is from spending that $60-$100 per month elsewhere.

  22. My parents (healthy, late 50s/early 60s NO medications) pay 3500/month.