Seventeen years ago Peter Shenkin had a
4,500 pound live oak tree fall on him while his high school class was
camping by the American River near Sacramento. Without the air
mattress he was sleeping on and being teased about by his classmates,
he would probably have been killed.
Thank God he wasn't. Instead,
he was transported to the nearest officially-designated trauma
center, Sutter Roseville Hospital. I'll skip the bad parts of his
care – the surgeons kept him waiting for hours before operating and
let regularly scheduled operations proceed, they failed to preserve a
kidney – and skip straight to the billing.
Pete was fully insured
by Blue Shield, the hospital was a participating provider, but
amazingly (if you didn't know how these things work) the trauma
surgeons, appointed as such by the hospital, were not Blue Shield
preferred providers! That is, they were not “in-network.”
Doctors sign up to be “in-network” so that they get more patients
and accept a lower fee for doing that, and the insurance demands much
less out of pocket payments from the patients. The trauma doctors
saw no advantage to themselves by signing up, so they didn't. How a
hospital could be in-network, and be a state-designated trauma center
and yet allow the doctors to be out-of-network – well, let's just
say that state law is sometimes deficient in their protection of the
public.
So our insurance paid for the hospital,
but we were expected to pay the full (very full) fees of the surgeons
above what Blue Shield covered. That's what is now called a
“surprise out-of-network billing.” Of course we didn't accept
it, and Blue Shield eventually paid it. But law and insurance being
what it is, can you believe when Peter got his settlement for the law
suit we brought for various malfeasances that led to the accident,
Blue Shield claimed tens of thousands of dollars of the settlement
for their own payment for medical services rendered? It's just hard
to believe. Despicable, really.
That was 17 years ago. You would think
that even the slow-moving governmental system would have fixed the
problem by now. Nope. It's just gotten worse, since insurance
companies have adopted “narrow networks” as their preferred
method of keeping costs down, which means offering very low payments
to providers and seeing who will sign up at those low levels, and
since only a few will sign up, the chance of being out-of network has
been magnified. So imaginative of the insurance companies.
Here is what Peter wrote to me about a
friend last week:
“(My friend) had apparently
reached his annual out-of-pocket maximum according to his health
insurance, and Sutter continued providing him care for his ulcerative
colitis. Sutter, though, did not inform Mike that the infusion
treatments being provided to him were 'Out of Network' and he would
be assessed a $399 charge each time. In fact, I am fairly certain
that Sutter even went as far as to promise that there would be no
charges for the infusions.”
Then just a few days later, Lola
and I were up at John Muir School with her old friend Yuval, as much
as a 6 ½ year old can have an old friend – they met at the “Nanny
Park” in Berkeley as 2 or 3 year olds. Yuval came up with an
unusual case of liver cancer, and has been well and successfully
treated, thank God. He's now fine, although hearing-impaired from
the treatment. Indeed, his father, Justin, said that they had just
had their valedictory visit to Lucile Packard Hospital; after this,
no more annual visits, just cured. It was a visit that lasted two
hours, during which he received an ultrasound exam and a blood
drawing for alphafetoprotein, nothing terribly special. Great, all
negative.
Then
came the bill. The bill. The bill was $12,000 for the visit.
$12,000. $6,000 an hour? But, being the forgiving institution it
is, Packard cut it down to $8,000. I wonder if they said “Just for
you!” And – you've been waiting for this – when the bill came,
that was when Justin discovered that Packard was now
“out-of-network.” So the family is expected to pay the balance
of the bill. Surprise!
He
will protest, he's a sophisticated guy, and I'll bet he won't pay.
But can you believe it? It's bad enough to raise the price to the
patient right in the middle of the process, but adding stealth?
So, what is the basic issue here? To
my mind, a big part of the problem here is the confluence of health
care and business. Clearly, health care has to think about business
economics. The past is horrendous. As my old attending pediatrician
Henry Shinefield said, medicine was given an unlimited budget and
they exceeded it. Medicine needs to be more mindful.
But mindful how? There is not just one
way of being “business-like.” There is the stolid, thoughtful,
rigorous costing and pricing and economizing and making efficient
activities of any business. The Main Street Ethic. Good! That's
what we need.
On the other hand, there is also the
Wall Street Ethic. What is the ethic of Wall Street? Lying,
cheating, stealing, and charity balls. They have elevated this into
“the American way of business,” as though this has always been
true, which it hasn't. They have even exported it. Talk about
obnoxious. Talk about rationalization. Talk about Trump as the
apotheosis, even though he doesn't have their “class.” Or
pretensions, better said. Or maybe he does.
The WSE says do whatever you can or
whatever you want, greed is good – yup, it's still with us. I
won't go on, the reader will have his or her own examples up the
wazoo, certainly from the newspapers, possibly directly from one's
own life. WSE is exemplified by the generic pricing scandal. If
it's not illegal, why not do it, if you will make more money? And
maybe it doesn't even have to be legal. Wells Fargo customers are no
doubt checking their statements.
The question, then, is which form of
business will medicine be adopting? Will trauma surgeons at a trauma
hospital be forced to accept preferred provider status, or something
similar? Will out-of-network charges be capped and applied to the
insurance companies rather than the patients? These are governmental
decisions at some level. In California AB-72 is on Governor Jerry
Brown's desk. It would limit out-of-network payments to 125% of
Medicare, with some other provisions, I guess. It is
patient-generated legislation.
It's too bad that this legislation had
to be patient-generated. At another level, isn't this something the
medical profession itself should be taking on?
Do we want to be stealth pricers? Do
we want to countenance prices like $12,000 for two hours of work? Or
do we want to voluntarily construct a system that eschews the WSE and
adopts the MSE instead, where pricing is both fair and transparent,
where efficiency is a goal, where patient service is a goal, where
the patient is treated with respect?
If medicine is silent and accepting of
how others structure our profession, if medicine does not stand up
for righteousness, the business of medicine will contaminate the
profession of medicine, and trust and respect will be further eroded.
There is no Chinese Wall between business and practicing medicine.
The medical profession should be standing up. The medical
organizations should be standing up.
They haven't so far. But will they?
That's really the basic question.
Budd Shenkin
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