Tag Archives: Health Care

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Cost comparison of brain MRI

I called Advanced Medical Imaging (AMI) in May 2014 to get a prior authorization for a brain MRI with and without contrast.

This is for a woman under 65 who is having short term memory problems. We are looking for treatable causes of short term memory loss. The blood work is negative. Next is the MRI.

Her MRI is already scheduled at the local hospital where I worked for nine years. It is the only hospital because we are a small county.

The AMI representative suggested that the patient get the MRI in Everett.

“The cost there is $917.00. It would be cheaper. It is only 29 miles away.”

“Yes, but Everett is across the sound. She’d have to drive around or take a ferry. What is the cost in Bremerton?” I asked. “At the radiology providers there?”

“The cost there is $967.00.”

“And where she is scheduled?” My local hospital has a “Rural Hospital” designation. Medicare will pay them more than other hospitals.

“$4585.00.”

I squeaked. “For the same MRI?”

“Yes.”

“Um. You should tell the patient.” Except that, is the patient willing to drive to Bremerton? And is the cost to the patient the same? And do they care?

“Do you want the prior authorization for that site.”

“Can it be changed if I talk to the patient?”

“Yes, she can call us.”

The prior authorizations are now site specific. That is, I’m getting approval for the MRI at a specific place. I have no idea why.* Seems stupid. Seems like just another hoop to remember to jump through and if we get it wrong the insurance can say, “Oh, ha, ha, ha, we don’t have to pay for that. You do.” Chalk up some more profit for the investors. Mission accomplished, money made.

I called the woman and explained. She was willing to go to Bremerton and said that she would call AMI. I asked her to call us back if she had any trouble.

The cost really matters to my medicare patients and any patient that has to pay a percentage of the cost. If they only have medicare part B, with no secondary, they pay 20% of the bill. 20% of 4500.00 is a lot more than 20% of $900. But some of my frailest most elderly most confused don’t really have a choice. Going 29 miles might as well be going to the moon.

And this is a woman with memory loss, remember? She wrote down the instructions and repeated them back to me three times.

Every phone call to insurance is like this, and makes me wonder about our culture.

* Actually, the authorizations are site specific because some places are “out of network” and the insurance won’t cover anything done there. Though I think the whole point of health insurance in the US is to try to remove money from people and avoid paying for care.

This was first posted at everything2 on Friday May 9, 2014. The woman died last month.

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Comparison of cost of abdominal CT with and without contrast

I keep reading that the US Health System should be a “free market” with competition.

To have an free market, one needs to be able to check the prices. I want to compare price tags. I have a patient who needs a CT scan of the abdomen and pelvis with and without contrast. So can I, as a doctor, find out the price?

I start making phone calls:

I call AIM Specialty Health, a procedure clearing house hired by many insurers here, to get prior authorization for the CT of the abdomen and pelvis with and without contrast. They ask for the usual identifying information: my name, tax id, NPI number, patient name, insurance number, check my address, phone number, fax number. They ask for theICD-9 codes — codes for the diagnosis. I know those. They ask for the CPT code, which is the procedure code for the test. I have to scramble to find the book and look it up: 74178. With the brain MRI the other day they volunteered site specific charges. Not this time. The representative said they didn’t know. I asked for prior authorization in Poulsbo, since that was most reasonable for the brain MRI. I asked what the patient’s copay is: AIM does not know.

Call to Premara Blue Cross, which is the patient’s insurance company. They can tell me that the patient has a $10,500 deductible each year. She will have to pay that much before the insurance pays anything. I ask them what it will cost at different sites. They say they can’t give me that information.

Next I call 5 different sites to get the price for that CPT code/proceedure.
Call to my local hospital: Charged amount is $4200.00
Call to a free standing radiology clinic in Poulsbo: Charged amount $1416.00
Call to the hospital in Bremerton, south of us: $8958.00.
Call to a free standing radiology clinic further south in Silverdale:$1526.00 + $20.00 for contrast.
Call to the hospital in Port Angeles, north of us: $ 3101.70 for the facility fee. Gave me Radia’s number for the physician fee.
Call to Radia and left message.
Left message with patient.

Radia called back and the fee is $346.80, so that would be added to the $3101.70 at Olympic Medical Center.

Now I know the amount BILLED at five sites. However, that is not the amount my patient will PAY.

If the site is “in network” then the site has a contract with Premara Blue Cross, which states the amount that Premara is going to pay. The patient will get an EOB, an explanation of benefits, from the insurance. “Benefits” is an interesting choice of words. The patient has paid for the insurance so that they will cover the bills. Is that a “benefit”?

On the EOB, it will state the amount that was billed for the service. Next it will state the amount “allowed”. “Allowed” is misleading. To me it implies that the insurance has held the cost down. But the insurance “allowed” the site to be “in network” because the doctor/site signed a contract. So this is a contracted price or agreed upon price.

I want to know the allowed/contracted/agreed upon price.

Call to the WA State Office of the Insurance Commissioner. The office says that the patient should be able to request the allowed cost for a specific site. Each site has a separate contract with the health insurance, so the allowed cost could be different at each site.

Call to Premara Blue Cross. This time they say that it’s not that they refused the information, it’s that it was not available. Now the representative says that they need the “units or minutes billed.” I don’t know what that is, but I will find out. I ask if that is the only other thing that I need. They say yes, but I cannot contact the same rep directly. I have to go through the rigamarole each time: my name, my tax id, patient’s name, patient’s insurance identification number, my clinic address, fax number, phone number, sometimes the patient phone number. Usually I have to punch 4 or five of these into the automated system and then have to repeat it all when I reach a human being.

Call to Poulsbo. The units refer to 100 units of contrast. Some patients will need more, up to 200 units.

Call to Premara Blue Cross again. I go over everything with representative Hailey, who then wants to know the amount that Poulsbo is billing. Explained that I was told only the units were needed. She put me on hold and checked with Poulsbo. She is quoted the same price.

Continuing with call to Premara Blue Cross. Hailey has entered everything and doesn’t get a result. She says she doesn’t know. I explain that they have a contract with Poulsbo that names an actual amount. She transfers me to another department after 25 minutes. The representative there says that she can give the allowed amount information to the provider doing the test, that is, to Poulsbo. I explained that the WA State Office of the Insurance Commissioner says that a patient can indeed request that information. I asked if they are refusing it to the patient. Rep repeats that she can give it to that provider but not me. I offer to have the patient in for a visit and get them on speaker phone and again request the information. Without the information, I will strongly consider filing a complaint with the state insurance commission. She decides to transfer me. That’s at 30 min and I am again put on hold.

The call to Premara Blue Cross ended after 45 min and 37 seconds and the third representative in the provider relations department states that if they get a call from Poulsbo that they could tell THEM the contracted allowable amount. Again stated that the insurance commissioner’s office says that the patient can request the amount. Are they and will they refuse it to the patient? Representative Whitney says that she has access only to provider accounts and that the contract with Poulsbo is proprietary information*. I say that I think health insurance is also a contract between the patient and the insurance and surely the patient can ask what it will cost in advance. I stated that I would be calling the patient and the state insurance commissioner’s office again.

I talk to the patient. She will now call the insurance and ask the “allowed” amount for this site. I give her the diagnosis code, CPT code and units billed.

She calls back. Premara says “around $600.00”.

I call Poulsbo and ask if they will check the contracted amount. They call Premara. They call me back.

If she only has 100 units of contrast, the CT of the abdomen and pelvis with and without contrast will cost her $641.00, as the “allowed” amount by contract between her insurance and the radiology site.

I still do not know the “allowed”/contracted amount for the other four sites, so I have failed in my attempt at comparing price tags. I only know the amount the sites would bill. The “allowed”/contracted amount for each site could be different. The hospitals bill more because they have a “facility” fee. I think this means that they are allowed to factor in various hospital costs. Even so, it seems outrageous that one hospital bills twice as much as the other two and more than six times as much as the least expensive site, but the allowed amount might be lower then the billed amount.

I don’t think this is a free market. I think it is an obscured market. And this is just one procedure and one single charge. Think of a hospital stay.
AIM Specialty Health http://aimspecialtyhealth.com/about-aim/guidelines
Washington State Office of the Insurance Commissioner is at http://www.insurance.wa.gov/
Premara Blue Cross https://www.premera.com/wa/visitor/
* When I called about the head MRI, why wasn’t the information about what is billed at different sites proprietary then?

This was initially posted on everything2 on Friday, May 16, 2014.

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Old men never die, they just spout poetry

When I was in residency we rotated through the Veterans Hospital in Portland. Most of our patients were either very elderly or they were alcoholics or addicts in their 50s, starting to really go downhill medically.

One elderly patient is particularly vivid in my memory. He was in his 80s and black. He was weak and had various problems. I was not doing a very good job of sorting him out.

He wouldn’t answer questions. Or rather, he would give a reply, but it was not yes or no and I couldn’t figure out how the answer related to the question.

On the third day he gave a long reply to a question and I recognized it.

“That’s Longfellow,” I said. He nearly smiled. “We did a bike trip around Nova Scotia and read Evangeline aloud in the tents at night. The mosquitos tried to eat us alive. That’s Longfellow, isn’t it?”

He wouldn’t answer but the twinkle in his eye indicated yes.

So our visits were cryptic but fun. I would try to guess the author. He knew acres of poetry, all stored in his brain, no effort. I tried to relate the poems to my questions to see if he was answering indirectly. I wondered if he had schizophrenia and these were answers, but I didn’t think so. I thought he was just stubborn and refusing to answer.

I challenged him. “Ok, you are the right age. Come up with a song with my first name that is from early in the century. My father used to sing it to me when I was little. Can you?”

The next day he sang to me: “K-k-k-katy, beautiful Katy, you’re the only beautiful girl that I adore. When the m-moon shines, over the cow shed, I’ll be waiting by the k-k-k-kitchen door.”

We sat and grinned at each other. Soon afterward I moved on to the next rotation. I don’t remember his medical problems. But I remember him and remember wondering what he had done in his life to have a memory and a store of poetry in his head. A teacher? A professor? A man who loved poetry? I started matching him with my own store of poems, the Walrus and the Carpenter, songs, bits and pieces.  I felt blessed and approved of when his eyes twinkled at me, when I recognized an author or even recognized the poem itself. I looked forward to seeing him on rounds, daily. And he seemed to look forward to my visits. I was sad when I had to say goodbye and the next rotation was out of town. And since he had never told us his name, no way to stay in touch. Farewell, poetry man, fare thee well.

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Mad as Hell: Good Insurance

My name is Katherine Temple Ottaway and I am a Mad as Hell Doctor!

I am a Family Practice physician. I live in a rural town of 9000 and I take care of people from birth to death. I have delivered babies for 18 years.

I am Mad as Hell because people are suffering and 30% of the money spent on health care goes to administration and profit, not to health care. 60% of bankruptcies in the United States are triggered by medical bills.

As we crossed the United States, doing town halls on single payer health care, I thought that we cared for our roads better than our fellow citizens. Rest stops and all.

My sister has “good” insurance, through the state of California. Four years ago, at age 41, she was diagnosed with stage IIIC breast cancer, advanced. Each year she pays a deductible of $500 and then a maximum copay of $3000 and then a maximum prescription copay of $1000 dollars. Last year she also paid a second deductible for her family, an additional maximum of 3000$ and the prescription copay for her family. Her cancer recurred in October of 2008 and the chemotherapy rolled over into January, so she is paying all of it again this year: at $4500 per year, that comes to $22,500 dollars over the last 4 years. And remember, she is lucky enough to have “good” insurance and she is lucky enough to have a boss who values her, so she hasn’t lost her job.

She was nauseated with her latest chemotherapy. Only one antinausea medicine worked. It was very expensive and the insurance refused to pay for it. She called them. They said, “95% of people on that chemotherapy have their nausea controlled with the other medicines.” “But I am in the other 5%,” she said. “We will not cover it,” they said. And they are lobbying Congress with $1,400,000 dollars a day. Where, exactly, do they get THAT money? My, they must have some really nice profits to protect.

My sister said to me sadly, “I wish I could save more for my daughter’s college.” Her daughter is 11. They rent and wish that they could buy a house. My sister said that she has nightmares about losing her job and them living on the streets.

And that is happening. People are making choices. They told us as we crossed the country. When a job is lost and the cobra insurance is $700 a month, it is often lost too. And then a cancer patient has to choose: treatment and my house will have to go to pay for it? Or do I preserve the house for my children and choose not to be treated? And possibly come to the emergency room at end stage, deathly ill, be treated with extraordinary measures in the emergency room and ICU. The house may still go.

I am Mad as Hell that we spend 16% of our GNP on health care, twice as much as the second most expensive system in the world, and yet are ranked 37th for over all health care. Our system causes deep suffering and horror for families. I am a Mad as Hell Doctor. Blessings on everyone that took Oct 15, 2009 to sit at health insurance companies. Peaceful social activism, to mourn the 45,000 Americans that now die prematurely from lack of medical care. Fight back.

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What I learned from my first Mad as Hell Doctor week

I spent a week with the Mad as Hell Doctors, as a Mad as Hell Doctor, doing town halls about health care and about single payer, HR676. We went from Seattle to Denver, with 1-3 town halls a day, and then I flew home.

They are still on the road and I rejoin them tomorrow, for the last week. We will end in Washington DC, with a caravan and a white ribbon protest at Lafayette Park on September 30, 2009 and October 1, 2009.

I have been home for just under two weeks and am STILL trying to sort out what I learned and feel. I suspect it will take months.

1. I am not alone.

2. I am not used to applause.

3. People are brave and noble.

First, I learned that there are other doctors who truly put patients first and will go on the road for 3.5 weeks to prove it.

Dr. Mike Huntington, a radiation oncologist. He says that in the last 10 years of practice, the treatment for prostate cancer tripled from $17,000 to $54,000 because of fancier technology and computers. The result? Minimal to no better results for the patient. It horrified him. He quit. He is on the road.

Dr. Joeseph Eusterman, an internist. He did internal medicine, that is, adult primary care, for 25 years. He was in the military. He then switched to Workman’s Comp. He was horrified to find how deeply frightened Americans are of their supervisors, of being injured, of speaking up when they are injured and how dysfunctional the system is. He is retired, over 80 years old, and is driving Winnie, the Winnebago, across the country. I pray that I am that strong and determined to do right in my 80s.

Dr. Paul Hochfeld, an emergency room doctor. About four years ago, he got furious at the system and started reading and searching for the reasons our health care cost so much. He started with that question. The writing that made sense led him to call the experts and he asked for interviews. He made a movie, titled Health, Money and Fear. He is furious that our political system is run by money, corporations and that Congress seems to have forgotten the people, with all the corporate money that is thrown at them. He is fighting for reform.

Dr. Robert Seward, an internist. He is horrified that 60% of bankruptcies in this nation are because of health care bills. Think of all the press on people losing their houses: the fact is, they are losing their houses in large part because of health insurance companies and the failure of health care in our nation. He spoke with a Canadian man on the trip, who said, “Why don’t you Americans take care of your people?” That is still echoing among us. Dr. Seward says, “I was ashamed. We don’t. We Americans don’t take care of our people and we could and I am ashamed.”

Dr. Margaret Flowers, a pediatrician. She is working for Physicians for a National Health Program (PNHP) as a Congressional Fellow. She wants single payer on the table in the Congressional discussion. She was arrested for refusing to leave Senator Max Baucus’s office in May 2009. She is fighting for single payer.

I had never met these people before I joined them in Seattle. I was nervous about it: a road trip with strangers and talk into a microphone? But it was like coming home and it felt right.

Second, I learned that I am armored against criticism: it’s praise that I don’t know how to handle. The day before the trip, I spoke to one of the doctors on the phone and he said that I wouldn’t be on the panel of Mad as Hell Doctors in Seattle. I would watch the first town hall and then be on the panel at the next, in Spokane.

At the last moment, they said, oh, no, you are on the panel. I hopped up and left my purse at my seat. I remembered it 45 minutes later and thankfully was able to retrieve it. It would have been difficult to fly home from Denver otherwise.

Each doctor had 1-3 minutes to say why they were Mad as Hell. I winged it, and that was not a problem, because I AM Mad as Hell at our present medical system, the drug companies, the insurance companies and could go on for hours. Other doctors at my hospital would no doubt roll their eyes and say that I DO go on for hours.

I am used to being ignored, marginalized, told “we’re concerned about you”, told “we want you to succeed,” pressured and fired. There were secret meetings about the call schedule that I was not told about because they didn’t want me there. I’m stubborn, used to it, speak up anyhow and armored.

But in Seattle, I said a 2-3 minute piece of what I’ve been arguing about for 20 years.

People clapped. Applause.

I sat down. I wanted to crawl under the table and hide behind the white sheet covering the front. I was dumbfounded. I didn’t know how I felt. I concentrated on what the other doctors were saying, one after another, instead.

The other doctors thanked me, glad to have a woman doctor, glad to have a family practitioner and a rural one to boot. At each town hall, we talked to anyone who came, before and afterwards. The program itself was about 90 minutes but with the time talking to people before and afterwards, it was more like three hours. We did one to three programs a day and drove in between. It was physically and mentally tough. Residency trains us to put away emotions until later, so that’s what I did. The doctors are all tough and no one wanted to complain too much with our 80 plus year old gung ho and tough as a boot.

After I got home, the strongest feeling was wanting to weep. My Death Panel writeup had been in the local paper and four people thanked me in three days. I didn’t know what to do with that either. Under all the armor is someone who wants to be appreciated and loved. I’m used to criticism but praise went through the armor straight to my heart and to a part of me that I didn’t know was there. That person appears to be rather young and undeveloped. She is going to take some bringing up. Meanwhile, I asked for help in the form of my improvisation teacher. How, I asked, do I handle applause? He gave me clear specific instructions. I can do what he said, even if the emotional stuff inside is hiding under the table. Doctor training kicks in easily.

Third, I learned how people from Seattle to Denver, across the country, will stand up if given the opportunity. Part of the program was the Mad as Hell Minute. ANYONE, whether they agreed with us or not, could come forward, say their name and be on camera. They said why they were Mad as Hell about health care. They did not have to agree with us, with single payer, they could argue the opposition. But everyone was supposed to listen. Adam Klugman, our creative director, spoke of how it was an exercise in speaking up to our friends and community members and an exercise in listening to each person. And anyone who spoke, might show up on Youtube.

At some programs, one person would get up to speak. People were shy. Then a second would get up, then two more and then we would have a line. Not everyone spoke, but most of the people at the indoor town halls spoke. They told heartbreaking stories of family members, friends, their own loss of a job with a loss of insurance and people who weren’t being treated, or died because they could not afford treatment.

They were brave and honest and that made me want to weep too. And it was inspiring, to see people speak up. I hope that Congress is watching the Mad as Hell Minutes. These are the people they should be listening to and responding to, not the 1-2 million dollars in lobbying paid for by the insurance companies DAILY.

I have been cursing up a storm in my diary. I’m going back on the road, leave tonight for Seattle, take my daughter to her grandmother, and rejoin the Mad as Hell Doctors for the last 6 days. I feel blessed. The cursing is to balance me out; there’s no room for the grumpy, irritable, argumentative part of me on the trip so it is having a field day before I go. Back to hear people’s stories and applaud. And I have faith that change is in the air.

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Obese smoking couch potato

I went on the Mad as Hell Doctor’s tour for a week. I went from Seattle to Denver with stops for town halls one to three times a day. We talked about single payer health insurance, HR 676.

One question or objection to a single payer system was: Why should my money go to pay for some obese person who drinks and smokes, doesn’t exercise and doesn’t eat right?

Three answers to start with:

1. You already pay for them.

2. Put out the fire.

3. People want to change.

First: You already pay for them. As a society, we have agreed that people who show up in an emergency room get care. Suppose we have a 53 year old man, laid off, lost his insurance, not exercising, not eating right, smokes, drinks some and he starts having chest pain. Suppose that he lives in my small town.

He calls an ambulance. They take him to our rural emergency room. Oh, yes, he is having a heart attack, so they call a helicopter to life flight him from small town hospital to a big one in Seattle. This alone costs somewhere between $7000 and $12000. Now, do you know how many clinic visit he could have had for $7000? To see me, a lowly rural specialist in Family Practice where I would have looked at his blood pressure and nagged, that is, encouraged him to stop smoking. We would have talked about alcohol and depression. And who is paying for the helicopter meanwhile? All of us. The hospital has to pass on the costs of the uninsured to the rest of the community, the government is paying us extra, with a rural hospital designation. 60% of health care dollars already flow through the government. One estimate of the money freed from administrative costs by changing to a single payer system is $500 billion.

Taking care of people only when they have their big heart attack is ridiculously expensive. It is a bit like driving a car and never ever doing maintenance until suddenly it dies on the highway. No oil, tires flat, transmission shot and ran into a tree in the rain because the windshield wiper fluid had been gone for a while. I get to take care of Uncle Alfred. He is 80 and has not seen a doctor for 30 years and is now in the hospital. “But he’s been fine,” says the family. Nope. He has had high blood pressure for years, that has led to heart failure, he has moderate kidney failure, his lungs are shot from smoking, turns out he developed diabetes sometime in the last 30 years and he’s going blind. Can’t hear much either. We have a minor celebration in the ICU because he doesn’t drink, so his liver actually works. He goes home on 8 new medicines.

Secondly: Put out the fire. When someone’s house is burning down, as a society we do not say, well, she didn’t store her paint thinner right or trim her topiary enough and she has too many newspapers stacked up. We go put out the fire. Putting out the fire helps us as a society: it keeps the fire from spreading to other houses. It saves lives and is compassionate. We think firemen and women are heros and heroines. And they are.

In the past, a homeowner would have to pay for fire service and would have a sign on their home. If the house was on fire and a different company was going by, that company wouldn’t put out the fire. We have the equivalent with health insurance right now. It would be much more efficient and less costly to have a single payer. Medicare has a 3% overhead: it is a public fund paying private doctors and hospitals. The VA is a socialized system, with the hospitals owned by the government and the medical personnel paid by them.

When someone asks why they should help someone else, I also know that they haven’t been hit yet. They have not gotten rheumatoid arthritis at age 32 or had another driver run in to them and broken bones or had another unexpected surprise illness or injury that happened in spite of the fact that they don’t smoke, don’t drink, eat right and exercise. Everyone has a health challenge at sometime in their life.

Third: people want to get better. Really. In clinic I do not see anyone who doesn’t hope a little that their life could change, that they could lose weight, stop smoking. True, there are some drinkers who are in denial, but I will never forget taking the time to tell a patient why he would die of liver failure if he didn’t stop drinking. He came back 6 weeks later sober. I said, “You are sober!” (We don’t see that response very frequently.) He looked at me in surprise: “You said I’d die if I didn’t stop.” He never drank again. It made it really hard to be totally cynical about alcohol and I can’t do it. People change and there is hope for change. I feel completely blessed to support change in clinic and watch people do it. They are amazing. But they need support and they need someone to listen and they need a place to take their fears and their confusion. Primary care is, in a sense, a job of nagging. But it is also a job of celebration because people do get better.

We are already paying, in an expensive, inefficient and dysfunctional way. It saves money to put out the fire. People want to get better. Winston Churchill said, “Americans always do the right thing after they have exhausted all other possibilities.” It is time to do the right thing. Single payer. The current bill is HR676. We can and we will.