An experience with a broken leg in Canada causes a doctor to reflect on the costs of healthcare in the United States.
My right leg was shattered. The tibia was in pieces and the fibula was completely displaced. The x-ray would confirm as much an hour later, but the situation was immediately apparent as I lay on my back, the engine of the overturned snowmobile still humming a couple of yards away. I looked down and saw my foot laying unnaturally flat on the packed snow. I tried to wiggle a toe, but I couldn’t.
My sister ran toward me in her snowsuit and rested my head in her lap. Then came a brutal, seemingly interminable sled ride down the mountain, with every imperfection in the snowy trails stabbing into my leg and shooting shocks up my spine. After I was transported via ambulance to a nearby clinic, x-rayed, drugged, and splinted, a second ambulance drove me 100 miles or so from Whistler, British Columbia, to a Vancouver general hospital, where I spent the night awaiting surgery.
Instead of celebrating at my brother’s wedding rehearsal dinner, I lay comfortably doped up in a four-bed hospital room. My mother sat in a chair near my mangled leg. She was draped in blankets and trying to sleep in this unnatural position. Across the way, separated from me by a half-closed curtain, a man snored in a deep, sonorous tone.
That night, I started along a path that has made me a better doctor. Not because I had an epiphany after interacting with an aloof physician or because I was a victim of a medical error, but rather because it helped me understand that, as a patient, money really matters.
A national doctor-patient issue
“How long do you think you’ll be in the hospital?” asked a woman from registration.
My eyes grew wide as I sat in the wheelchair. I shrugged.
“Did the doctor give you an estimate?” she asked.
I told her 3 or 4 days. I was a bit distracted, because in 2 hours I was scheduled for the operating room, where a metal rod would be hammered into my tibia.
“We’ll go with 3,” she said.
Upon receiving a printout some moments later, I discovered that this particular surgery, plus a 3-day hospital stay, cost nearly $15,000 in Canadian money. I put it on my credit card. Later, I wondered what would have happened if I couldn’t have afforded the fees, or if my credit limit hadn’t been high enough.
The nickels and dimes of care
Before this injury, I’d had very little exposure to the nickels and dimes that drive medical care. During my residency, the few times the topic came up, it was drowned out by some variation of, “Money doesn’t matter; we do what’s best for the patient.”
Then I took a job working as a hospitalist in an academic center, where faculty members are often far removed from the realities of healthcare costs; the focus, instead, is on protected time and resident work-hours. I never asked how much patients were charged.
As a junior faculty member, I simply put check marks next to Current Procedural Terminology (CPT) codes based on how much time I’d spent and how many “systems” I’d reviewed. Twice a week, I placed those hard-copy billing sheets in a file cabinet, and by the next day they had mysteriously disappeared. In the meantime, I continued to see patients and put check marks next to more CPT codes.
Occasionally, the division director would ask for ideas on how to increase the census. But once, when George W. Bush was president and actively championing high-deductible healthcare plans, and before my leg was split into pieces, I received an enlightening phone call from the mother of a patient, asking me to waive some of the fees I’d charged for a lengthy hospital stay.
“Please consider it,” she pleaded on my office answering machine. “We’re having some trouble paying.”
To my lasting embarrassment, my efforts to problem-solve ended with a conversation with an office staff member, who had no idea where to forward the request. She’d never heard such a thing, she said, and then she told me that she would call the family with a general number for accounts receivable. I had no idea what authority I had as a junior faculty member to waive physician fees.
Also around that time, through my public health coursework, I was becoming familiar with seemingly important numbers such as the gross domestic product and national healthcare expenditures. I started to recognize that trillions of dollars were being spent each year on healthcare and that our society is insatiable in its demand for high-quality, easily accessed, equitable healthcare for all.
Ultimately, it struck me that this was the early part of a potentially nasty, prolonged national conversation. Can one mother’s plea for fiscal leniency be easily inserted into the healthcare debates that members of Congress are having in Washington, DC.? How do my physician fees affect the trillions of dollars spent annually on healthcare services? If I waive these fees for this particular mother, will I be helping an unfortunate family pay its bills while also doing my part to decrease the national debt?
I watched the evolution of the Affordable Care Act with a keen eye and measured skepticism.
Another day, more money owed
On day number three of my hospital stay, a young man came into my room and politely informed me that I’d underestimated my stay and that more money was due. I again handed over my credit card.
“Don’t see this too often in the states,” I said.
Had I been a Canadian citizen, the operation and hospital stay would have been covered in full. In the 2007 documentary Sicko, Michael Moore reported on the Canadian healthcare system. Some people are big fans of this model and wished the United States would have implemented it, fervently believing in a maple-syrupy sweet resolution to our healthcare cost woes.
I didn’t mind that I had to pay out of pocket. Other than a visit to Niagara Falls and a medical conference in Vancouver, I hadn’t contributed much to the Canadian tax system. Also, I was insured and knew my insurance company would reimburse me for most of what I’d spent once I returned to the United States.
And the remaining balance? I’d accept that as the penalty for going too fast on a snowmobile.
But the introduction to the reality of healthcare costs, and the lack of insulating layers between provider and patient when it came to the exchange of money, is a lesson that I still bring with me to the bedsides of the patients and families I see.
The bills continued to pile up. One from the ambulance company-an expense I hadn’t even considered-came to nearly $500. The clinic that had done the original splinting and x-ray-but hadn’t insisted that I pay in advance, perhaps because I was still in excruciating pain with a wrong-way-facing foot-sent a bill for just under $1,000. Then the hospital billed me for some residual expenses that I hadn’t anticipated preoperatively. This wasn’t a line-item bill. Rather, it was a summary bill that exhibited the total charges, documented what I’d already paid, and requested that I pay the balance immediately.
After I’d returned home and sought follow-up care, I realized that I had only a single medical record in my possession. Not the computed tomography (CT) scan that had been performed looking for vascular compromise, nor the operative note identifying the procedure and type of medullary rod that had been inserted. Only a pink discharge paper, telling me to get physical therapy three times a week as soon as possible.
So I wrote the following letter:
To Whom It May Concern:
Thank you for taking good care of me. I look forward to paying this bill in full. However, before I do so, can you please send me a) an electronic copy of my CT scan, b) the operative note, and c) an itemized bill identifying each charge separately?
The quest for transparency
Over the years, several patient encounters have hit my olfactory with a familiar stench. I have written letters drawing on my experience as a physician and health policy wonk. I can only imagine what administrative staffers think when they open my notes.
But I am in a rare position, with a knowledge base that most patients don’t have. Why, if insurance companies pay people to do utilization reviews, shouldn’t I be able to advocate similarly for myself? Why, if I’m being asked to pay extraordinary prices-either out-of-pocket or through a third-party intermediary-should I not expect extraordinary, holistic service that includes after-the-visit patient support?
It seems strange that I was asked to pay more than $1,000 for a CT scan, yet the results of this scan were held hostage until I made several phone calls and paid even more money. I’ve faced this particular issue several times in seeking to get medical records that belong to me and that I believe I’ve already paid for.
It also seems strange that charges for services would be lumped together so I can’t decipher the specifics, interpret the appropriateness of the bill, and understand the billing documentation of medical services provided. I’ve had to address this issue in multiple letters, to multiple providers.
In other instances, it has seemed strange that my medical records from a doctor’s visit were so difficult to obtain, that my lab results were withheld even after my direct request and proof of identity, that my personal letters went unanswered for several weeks (although the notifications of payment delinquency were quite timely), and that the charges associated with simple services were so obscenely high.
Talking about costs
As physicians, we are in many ways obligated to know how the decisions we make will affect our patients financially, and we should consider strongly having frank discussions about cost and value in partnership with the people we treat. These days, I try to make myself accessible to patients who have questions about processes or billing. Although I may have made good clinical decisions, I recognize that frustrations could arrive later in the form of billing statements that camouflage fiscal complexities.
Now I am now as transparent as I can be with economic details, and I make sure to include practical fiscal considerations in the teaching points I offer residents and medical students. I don’t shy away from telling families how costs can come into play, and I try to anticipate some things they can expect in the future. I also think it’s important that I know what insurance a patient has, not because it will change a clinical decision I make, but because it will make it easier for me to transition a family smoothly into an outpatient setting.
All things considered, I suppose I’m writing another clichéd tale of how being a patient made me a better doctor. But it’s true.
The author is director of the division of pediatric hospitalist medicine and medical director of inpatient wards at Children’s Hospital of The King’s Daughters in Norfolk, Virginia. Send your feedback to firstname.lastname@example.org. Also engage at www.twitter.com/MedEconomics and www.facebook.com/MedicalEconomics.