A Healthy Bottom Line
While I was reading Dr. Elisabeth Rosenthal’s new book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, I received a bill for $1,980 for anesthesia provided during a routine colonoscopy. My physician was in-network and the insurance company had signed off on the procedure, so I hadn’t thought to ask if I would be charged for any other services. It turns out the anesthesiologist was not in my network, and I had not been told.
Dr. Rosenthal, who worked as a physician before she became a journalist for The New York Times 22 years ago, covers exactly this scenario in her book. “Argue against surprise out-of-network bills,” she writes as if she were addressing me directly. “Informed consent is a bedrock legal and medical principle,” she adds. “You were not informed of the out-of-network status of these providers and did not consent to them participating in your care. The doctor and insurer will have to work out a fair price themselves.”
I took her advice. Armed with an understanding of the system and the exact terminology to use, I contacted the biller. The doctor and insurance company are now duking it out.
In an interview, Dr. Rosenthal, 61, says she is outraged at the “transformation of American medicine in the last quarter century from a caring endeavor to the most profitable industry in the U.S.,” with American health care consumers spending more than $3 trillion a year, nearly a fifth of the country’s GDP—about the equivalent of the entire economy of France. “Financial incentives to order more tests,” she adds, “drive much of our health care.”
She wants other people to use their anger both to stand up for themselves and to advocate for systemic change. To do that, she offers a plethora of practical self-help strategies and politically viable “fixes” (see sidebar, at right). “This is a call to arms,” she declares, “as well as a road map for us to fight back personally, politically and systematically. Many families are spending 20 to 30 percent of their household income on insurance costs for hernias or broken wrists—more than on housing or food. Think of the things we could do with the money—like sending our kids to summer camp!”
“We can’t count on Washington to fix this for us,” she adds.
Dr. Samuel Klagsbrun, a psychiatrist and the owner and executive medical director of Four Winds Hospital in Katonah and Saratoga Springs, N.Y., shares her concerns. He says the concept of tzedakah is front and center at the mental health facilities he took over 41 years ago. “Outrageous charges are shameful,” he says, expressing his own “feeling of rage” at managed care, which has “kicked patients out of my hospital too early.” He recalls the case of a 17-year-old actively suicidal boy who was denied inpatient care. “I was livid,” he says. “We kept him at our own cost.”
He receives requests for reductions in fees “all the time,” Dr. Klagsbrun says. His decisions are based on private discussions and individual contact rather than a standardized system, he explains. If you feel you cannot afford care or a bill is too high, he suggests a straightforward approach: “Just ask.”
Dr. Rosenthal says that an understanding of the system goes hand-in-hand with empowerment. Treat health care charges as you would any other bill, she says. This and other recommendations may change how much individuals pay for health care and then, she contends, the broader system will gradually respond. “In health care,” she says, “we’re timid. We think the system or our doctor knows best.”
Heather Pearce Campbell, an attorney in Seattle, wrote to Dr. Rosenthal at The New York Times after she received a $45,000 bill for “miscellaneous” charges after surgery for an ectopic pregnancy in 2014. Her portion was $3,000. She disputed the hospital bill and asked for an itemization, but never received one. When the hospital threatened to send the bill to collections, she filed a complaint with the state attorney general for “deceptive and obstructive billing practices.”
Despite her critiques of the system, Dr. Rosenthal stresses that “there is a natural alliance between health care professionals and patients who mostly want the same thing: patient-centered, evidence-based affordable care. Many doctors feel as helpless and distressed as their patients.” She cites Dr. Hans Rechsteiner, a Wisconsin surgeon who once had a patient contact him after receiving a hospital bill for $12,500.
“I had always felt good that I’d saved a patient’s life by a simple act like taking out an appendix,” he said. “I realized right then I was bankrupting them, too.”
Dr. Rosenthal argues that providers have leverage over hospitals to demand better and less expensive services, but they need to shift their roles and become more educated in navigating the maze of pre-approval, coding, pricing and billing.
Steven Brill, lawyer, journalist and author of America’s Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System, says he is “skeptical about the idea that if only Americans were better, smarter, tougher consumers then the health care system would be fixed.” Consumer power is limited, he says, because “people don’t have much of a choice in almost every health care purchase. It’s not like we wake up every day and say, ‘Gee, what’s on sale in the ER?’”
His experience as a patient who paid $12,000 of a $190,000 bill for open-heart surgery led to a Time magazine article in 2013 and then a book two years later. When it comes to health, says Brill, psychological factors also come into play. “If your child needs a new heart valve, and you are given a choice between one that is 100 percent effective and one that is 90 percent as good but half the price, which would you choose?” he asks. “The 100 percent.”
Changing the system to control profits and prices like every other country in the world, says Brill, raises a major problem. “In the U.S., health care is 20 percent of the economy, and that 20 percent has the largest, most powerful lobby in Washington,” he explains. “In every other country, it is 10 to 12 percent. We would be killing 8 percent of jobs, of the economy. Politically that’s impossible.” His suggestion is to expand Medicare by lowering the eligible age by two years every year until, after 20 years, the United States has a single-payer system in which the government dispenses most of the money to providers.
Dr. Rosenthal says her focus on health care is “deeply personal.” She was raised in Scarsdale, N.Y., in a family of physicians and absorbed the Jewish values of compassion and service early on. Her father, who passed away at age 45, was a pediatric oncologist; his twin brother was a primary care doctor. “The book has its roots in their practice, which was about taking care of patients,” she says. She recalls the many gifts patients who could not pay sent to her father’s office. “It was a pre-insurance world. You didn’t do it for the money. You did it because you wanted the world to be a better place.”
A Harvard-trained physician, Dr. Rosenthal worked in the ER in what is now NewYork-Presbyterian Hospital, freelancing as a writer on the side. “I have watched the slow heist unfold,” she says. “It’s been painful. I care about the profession and the patients.” She says she would find it hard to practice today in a system that is so flawed. “As a writer I can call attention to those flaws.” She recently became editor-in-chief of Kaiser Health News, a nonprofit investigative news service focusing on health care.
Dr. Rosenthal gathered most of her stories for the book on her Facebook page Paying Till It Hurts, which now has just under 8,500 followers. “This is about real people,” she says, “just like you and me.”
Rahel Musleah, a regular contributor to Hadassah Magazine, also runs Jewish tours to India (explorejewishindia.com).
Heath Care Costs: What You Can Do Right Now
1. Doctors’ Bills
Ask questions about care and its price tag beforehand. Why is your doctor ordering a particular test? How much will it cost? Will it change your treatment? Are there cheaper alternatives to the lab test or drug that the doctor has recommended? Who else may be involved in your treatment?
2. Hospital Bills
Vet your hospital. Check customer reviews online and consider the hospital’s safety record through the nonprofit Leapfrog Group.
Ask the right questions. Is there a cost for the private room you have been assigned? Are you being admitted or held on observation status, which has higher fees? Ask the identity of every unfamiliar person who appears by your bedside.
Before you sign any documents that ask if you will accept financial charges not covered by your insurer, write in “as long as the providers are in my insurance network.” If you receive an outrageous bill, negotiate; request complete itemization; record your protest in writing to create a record; and argue against surprise out-of-network bills.
3. Insurance Costs
When selecting a plan, look at several key factors: your premium, deductible, co-payments, annual out-of-pocket maximum and the network of doctors and hospitals.
Work backward to choose the best option. If you want to stick with your current doctors, ask for a list of plans in which they participate. If someone on your plan has a serious medical condition, maybe the most important factor is a particular hospital or doctor.
4. Drug and Medical Device Costs
Shop around. GoodRx.com gives the cash price of every medicine at local pharmacies and provides discount coupons. The full cash price may be less than your
co-pay. You do not have to use your insurance.
Consider imports. The cost outside the United States of certain drugs can be significantly lower. If you are traveling abroad, carry a prescription and fill it there, or use an overseas mail-order pharmacy for long-term medications.
Adapted from An American Sickness: How Healthcare Became Big Business and How You Can Take It Back (Penguin)