A patient nearly died to save him $1110

Where I’m from, you can have someone killed for $5000.  I will do it for $1110. I’m a hand surgeon.

I practice (or practiced, by the time you read this) in an area that is what we often refer to as “underserved.”   Rather, the area isn’t, but the people I treat are.  I work in a large urban referral center that has a very high proportion of Medicaid as well as unfunded patients.  No one else in town will touch them.  I am not blaming them — they are in private practice and they can’t cover their expenses if they are paid nothing or close to nothing for their time and supplies.  While there may be an element of greed, it is not all greed.  I know my colleagues in private practice and almost without exception, I respect them all as physicians and people.

In my referral center, the hospital has favorable contracts with Medicaid that yield good revenue for the center from Medicaid patients.  But, as a consequence, all of my procedures are “hospital-based” as opposed to “clinic-based.” It is a semantic billing distinction that I do not completely understand myself (another part of the problem) and it allows the hospital to generate enough revenue to cover costs for an unquestionably needy population.  For the patients with Medicaid, it allows us to care for them with little, if any out-of-pocket cost to them and keep the lights on.

However, for patients with private insurance that is anything less than a top-of-the-line plan, procedures done in outpatient “hospital-based” clinics are not covered and are billed at very high rates that come out-of-pocket.  A steroid injection for tendonitis can yield a bill in excess of $1000.  Doing a simple wound “clean-up” or debridement can be north of $1100.  I am on salary and don’t make an extra nickel either way.

Which is why when Mr. Jones, an overweight diabetic with private insurance presented with a small local infection that I probably could have addressed in the office, I took him to the OR.  His insurance company would only cover the costs if it were done upstairs, but would pay nothing if I did it in my clinic.

Once in the OR, the regional block he received did not work well (which happens) and his sedation was increased.  The increased sedation made it difficult for him to breathe and he had to be ventilated emergently.  He lost his airway.  His oxygen saturation dipped below 60% of normal, briefly, and the anesthesiologists were able to right the ship and wake him up.

Ultimately, things went well.  The patient’s hand was healed and he didn’t face a medical bill that would have decimated his financial health.  However, I nearly killed him to save him $1110.

Robert Gray is a winner, 2013 Costs of Care Essay Contest.

A patient nearly died to save him $1110

This post originally appeared on the Costs of Care Blog. Costs of Care is a 501c3 nonprofit that is transforming American health care delivery by empowering patients and their caregivers to deflate medical bills. Follow us on Twitter @costsofcare.

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  • Patient Kit

    Thank you for another good example of the insanity that is our healthcare system. I’ve spent the last year and a half trying not to die of ovarian cancer in that system.

    When my suspicious cyst was initially found, I was just about to lose the Blue Cross provided by my former employer. Then I spent 4 months uninsured and not seeing any doctors until I qualified for Medicaid. Six months after the cyst was found, I was finally able to have surgery once I was covered by Medicaid. And it’s a good thing I didn’t wait any longer because it did turn out to be cancer, still early stage.

    Now I’m looking to get myself back to work and off Medicaid and it’s a total mystery going forward whether the next phase of this odyssey will see me uninsured again, underinsured or adequately insured. It’s a total mystery going forward whether I will be able to access the follow up care and monitoring that I’m supposed to get — or not.

    I’ve been terrified the entire time during this journey, not of the cancer but of our healthcare system. I can totally see why many people just give up on trying to get the medical care they need.

    • Deceased MD

      I admire your strength. I can only imagine how dificult this must be. Please educate me. If you get a job, hopefully employer would cover. but if not, wouldn’t you at least benefit from the ACA and be able to get coverage where you are or are you thinking it would be cost prohibitive in some way?

      • Patient Kit

        As of January 1, 2014, the ACA does prevent health insurance companies from refusing to cover me for my preexisting condition. My best hope is finding employment that provides a good health insurance plan, for which I’d pay some reasonable portion of the premium. But, that’s proving easier said than done.

        If I end up working for an employer that doesn’t provide an insurance benefit, I can try the exchange. But those plans, except for the most expensive one, are pretty bad plans. High deductible and high co pay. Since I’m starting over from being completely broke, if I don’t have that first $5,000 deductible (which I don’t), I’ll be paying for insurance but won’t be able to afford to go to the use it anyway. The bronze plan has 50% copays of everything — docs, hospital, surgery, etc. The other problem with the exchange plans, of course, are how few doctors, hospitals, etc are accepting them.

        The cap on out of pocket expenses would save me if my cancer recurs and I need another surgery. But, in the meantime, I won’t be able to afford to pay out of pocket to see my GYN ONC or my primary care doc on the regular basis that I’m supposed to be seen for follow up monitoring. If I take a really crappy low-paying job, I might still be eligible for Medicaid for a while. But I won’t be able to keep a roof over my head unless I make more money.

        It’s not that I object to actually paying for healthcare. I COBRA’d my Blue Cross for as long as I could at $700/mo. It was one of my two top financial priorities along with not becoming homeless. But now that I no longer have any savings or cash, my healthcare options are becoming more limited. Once I start working, I’ll likely make just enough money for Medicaid to cut me off. That’s when the exchange plans were supposed to be useful. But we all know that the exchange plans aren’t turning out to be the magic answer.

        Sigh. I know I shouldn’t but I have to seriously consider the option of just taking my chances — and a huge leap of faith — and not seeing any docs for a year or so unless something really bad enough to bring me to the ER. I can try to self treat anything short of true emergency. Honestly, I’m so exhausted from going through this cancer odyssey under ever-changing health insurance circumstances, I’m seriously considering giving up on accessing our system for a while. Or I’ll dig deep and find some way again to get what I need from healthcare.

        Sigh. Sorry for the vent and thanks for listing to it. I feel like I’ve been walking on a highwire tightrope without a net for a year and a half now. I know, I know. Whatever I do — don’t look down.

        • Deceased MD

          You should take this post here and publish on here. Seriously, this is incredible. You sound bright and motivated. You do still have medicaid, right? keep that as long as you can!
          So query. If you have to buy your own insurance it would be $700 per month and $5000 deductible? Without getting nosy, wondering , in your area, how much an individual would have to earn to be able to even just break even, with housing, health costs and the essentials? It seems like this issue is crippling to the middle class and ir seems clear that the ACA does not really help with medical bankruptcies as I believe was intended. Well I truly am sorry you are going through all this on top of the illness. Keep the medicaid for at least the 5 year period. You are bright. ia m sure some lucky place will at the very least start you out with admin-although you sound more talented and capable but it’s a start. Best of luck to you.

          • Patient Kit

            Thank you. As always, I appreciate your interest, your empathy and your outrage.. I decided to start posting here on KMD, not because I wanted to relentlessly complain about my situation but because I wanted to share my personal story in hope that readers might start to get to know me as an individual and I could add a patient’s voice to the conversation here about how the US healthcare system is failing us.

            I do still have Medicaid for the moment and I will say that, with all of it’s problems, I have found ways to get excellent medical care covered by Medicaid. But Medicaid is a stopgap temporary thing for me. I’ve been on Medicaid for a little over a year. As soon as I start working, they will likely cut me off, unless I take a minimum wage job at McDonald’s or Walmart. And I can’t survive on $8/hr. I live in NYC.

            Before all this happened (Achilles surgery/layoff/cancer dx), I was living a simple but happy middle class life, working in Manhattan and living in Brooklyn. My last salary was $52,000/yr but my employer paid my full premium on my Blue Cross policy and it was a really good policy with no deductible and reasonable copays. I worked hard for long hours but I was doing work that helped people and I’m not very materialistic, so I didn’t need a lot of things to be happy. My employer was a nonprofit so we got decent benefits to make up for relatively low salaries.

            Even if I take a big cut in salary and do work way below my experience and capability as an admin asst that pays, say, $40,000, I’ll make way too much to stay on Medicaid but too little to afford to pay for my own
            healthcare (especially knowing the specialized medical care I need). I may be able to stay on Medicaid for a brief transitional period once I start working. Maybe a few months. The exchange subsidies help people pay their premiums but it’s meaningless if we can’t afford the copays and high deductible. Also, let’s not forget that a gross $40,000 salary nets more like $30,000 once federal, state, city taxes, etc are deducted. Economists tend to talk about gross salaries. But net pay is all real people actually have to work with.

            I do think that whoever ends up with me as their super duper admin asst is going to be one lucky boss, LOL! I just hope they provide some reasonable healthcare plan. But from what I’ve seen so far, I’m not counting on it.

          • Deceased MD

            We are all rooting for you. It has been an education for me to read your story. It all makes sense but I never realized that in this day and age one really cannot afford to become ill!

          • Patient Kit

            Again, thank you. Even now, I identify far more as a survivor than as a victim. I have my moments when I feel like giving up. But unfortunately, I think it’s my nature to go down swinging, if down I must go.

            It saddens me that there are doctors out there who don’t realize what patients like me are going through. Because there are millions of us. So, I guess baring my soul and telling my pathetic story in all it’s gory detail is worth it if I’m succeeding in making anyone more aware of situations like mine.

          • Deceased MD

            I have worked in different sorts of settings with all kinds of socioeconomic status. But things are changing rapidly. When I started, I was aware that illness caused financial stress of course,but not anywhere the degree of where we are now. But I can see from your experience and from the insane costs of HC that the average hard working individual can no longer afford it. It is so wrong!

          • meyati

            My grandson was working his way through college. This is the only state where the wages went down. He left and went to a friendlier state. He made $7.00 a year too much for Medicaid, The ACA deductible and premiums are more than his income. I have incurable cancer, so I gave him my car. I’m in remission, but I still have problems. He drove me for treatment and helped keep the house clean. My son is a disabled vet, and the plan he signed up for is one of the worst the military has had. So my grandson was helping him too. It’s the overall picture of the state’s lack of economic viability and the financial demands of ACA.

          • Deceased MD

            so very sorry to hear that but I can see this is devastating for many.

          • Patient Kit

            It is wrong. I live continuously on the verge of moving to Doc Buzz’s dark side and abandoning all hope (in our healthcare system). If I’m going to be a cancer patient in remission with zero access to doctors, here’s hoping that the force will be with me during the journey ahead. I fought hard to get the medical care I needed this year but I’m getting close to tapped out and just opting out of our healthcare system completely is sounding better and better.

          • Deceased MD

            lost the other post. dont jump ship yet Kit. focus on a way out for yourself. no helping fix the system. Don’t mean to make light of a most difficult situation but don’t give up yet. All you need is one job or possible to stave off sith getting medicare at this point? i am not a LCSW –don’t let this blog make you think there is no hope for you personally.

          • Patient Kit

            Thanks, DMD. I’m probably just having a bad day. The good news is that, if I do jump ship, at least I’m a strong swimmer. There’s that. But, as someone who does jump off of real boats into the actual ocean, I usually like to have the option of climbing back onto the boat when I get tired or there are signs of sharks. But yeah, KMD can be pretty depressing sometimes. And yet, I’ve grown to love it. I just have to remind myself that I’ve survived worse than what I’m going through this year. 9/11 comes to mind. And I’ll somehow survive this too. If it’s the last thing I do. ;-)

          • Deceased MD

            Wow you must be a good swimmer. Hang in there Kit!

          • Patient Kit

            Thanks! I just finished swimming my daily 36 laps (a mile in my local Y pool) and I feel a lot better than I felt earlier today. Swimming is good therapy for both body and mind. I’m addicted to it. Can’t wait until the ocean warms up around here.

          • Deceased MD

            I’m impressed. Maybe soon you’ll be ready for the English channel.

          • Patient Kit

            No, never. I’m just an average mermaid. And one who prefers warmer waters when possible. Before I fell out of the middle class, I was spending some time in Mexico in the lovely Carribbean Sea swimming with the stingrays. But, until I can claw my way back to my former life, all I have is my local Y pool (thanks to a good friend who paid for my membership this year) and the cold Atlantic off the south coast of Long Island. Once it warms up, I can swim in the ocean into October. Swimming is definitely one of my lifelines to sanity.

          • DoubtfulGuest

            Love it — Are you the one who wants to swim with whale sharks someday? I saw that on another post. That’s on my list, too. I need to learn to swim better. And I need a bit more stamina…okay, a lot more. But it’s something to work up to. I hope you get to go back to Mexico and your stingrays soon. :)

          • Patient Kit

            Thank you. And, yes, swimming with whale sharks is on my long bucket list. I hope we both get to do that some day soon. Who wouldn’t want to swim with a gentle giant with a 5 ft wide mouth? ;-) We all have to have goals to get us through the tough times.

          • SarahJ89

            DMD, I know several people in her or similar shoes. My state refused to expand Medicaid so my friends’ daughter–who lives in her parents’ barn where she works as a hired hand–is too “rich” for an ACA subsidy but obviously cannot afford insurance on a hired hand’s wages.

          • Deceased MD

            Sorry to hear that. I have seen that coming in all the states that have refused to expand medicaid. Eye roll. It’s really pathetic.

          • SarahJ89

            Hi there, DMD,
            The income limits on Medicaid are so low I doubt Pt. Kit would be able to continue, except on an in-and-out basis–which is kind of like having a part time job because of the paperwork and documentation required.

            I don’t know if you have to be permanently (i.e. at least a year) and totally disabled, either, for Medicaid in her state. You used to have to be in mine.

            Pt. Kit,
            I get a lot from hearing your story. You are definitely adding to the conversation about health care and achieving your goal in writing. Thank you.

          • Patient Kit

            Thank you, Sarah. I appreciate your kind words. It’s been quite an experience falling out of the middle class and into my current situation. Believe me, I hesitated before baring my soul here on KMD. Sometimes I end up crying while writing about my own story here. It puts me very in touch with how vulnerable I really am. But I felt like the benefits of speaking up might outweigh the risks. There has been a learning curve trying to figure out how to make Medicaid work for me during real crisis. I have always intended Medicaid to be a temporary measure until I could get back on my feet. It’s kind of murky whether I’ll be able to keep the Medicaid for a little while while I transition back to work. Maybe, maybe not. My only real hope of being able to see any doctors going forward is finding a new job that comes with a decent health insurance plan. So far, I haven’t found that.

            The ironic thing is that, if I lose Medicaid because I start working, but can’t afford the healthcare I should be getting and stop seeing any doctors for the next year or so, if my cancer recurs — and the next time is not found in an early stage — I would have to stop working again and I would end up costing Medicaid much more money to treat me for a serious illness that could have been prevented much more inexpensively had I been able to afford regular monitoring checkups.

            There are many of us — millions — out here in my situation. Some are the working poor, others have
            recently plummeted out of the middle class. And the
            ACA is not the answer to all the people, like your friend’s daughter, who are still falling through the cracks of our system.

          • SarahJ89

            Keep talking about it. It’s difficult but important work. And yes, you are correct about the irony of the long term costs. It’s the nature of bureaucracy to be unable to look beyond the perimeters of the little box in which one works. To be honest, if you keep looking at the larger picture you’ll go mad. I quit when I got tired of opening my mouth and having silly stuff come out.

  • Markus

    If you had done the procedure in your office, would you have not used anaesthesia? If he had become oversedated in your office without the extra people and equipment that is standard in OR’s, would not the situation been more perilous?
    BTW, charging $1 000 for a steroid injection seems like a lot to me.

    • Dr. Ivo Robotnik

      Without knowing the exact size and nature of the infection we can only speculate what would have been needed in the office. But he already stated he’s paid on a salary, it’s the hospital group he works for that sets the $1000 steroid injection. They’d probably justify it for the cost of the steroid, syringe, needle, antiseptic, facility fee, appointment time, gauze, packing, and then the actual debridement itself.

      It’s outrageous, but as patients and hospital based doctors, there’s little we can do to change that price. Though an insurance company could probably bargain it down to a substantially reduced price.

      • dontdoitagain

        Dr. Robotnik (cute) you have hit the nail on the head. It is OUTRAGEOUS that an injection should cost $1,000. This is what needed to be addressed in any health care “reform”. Instead our government decided in its infinite wisdom to play some kind of shell game to try to cover the COST. Plus there are some very large “incentives” aka taxes to make sure that medical coverage continues to be astronomically expensive. If medical care were affordable the government wouldn’t get all those lovely taxes. 3.8% tax on Obamacare plans for a start. Tax on home sales, tanning salons, medical devices, larger income taxes and on and on. The government wants their cut of the money to be made in health care. (they did it with home mortgages and we see how well that worked) They also want the ability to seize any assets you may have to pay them for providing medicaid. They will kindly wait until you die (for now) and then take everything. One illness could pretty well cover the taking of your house, cars, bank accounts etc. They couldn’t do this if medical care were affordable.

  • Suzi Q 38

    Doctor, I thank you for your story.
    We need to be more aware of the risks in agreeing to surgeries.
    We need to ask more questions and get more answers for various alternatives, pros and cons, BEFORE the big event.

  • Patient Kit

    I’m confused. I thought swimbikerun is a patient, not a doctor. But maybe I read and interpreted incorrectly?

    • Suzi Q 38

      LOL. No you didn’t, I read it wrong. It was much to early this morning.
      For a minute there, I thought that Swimbikerun was a doctor.
      Thanks for letting me know.

      • Patient Kit

        Thanks! For a minute there, I was questioning my sanity. (And I will admit that I drank my share of tequila last night.)

  • Patient Kit

    I’ve been very lucky to have mostly good doctors, a few adequate and no really bad docs. My issues are with our system, not with individual doctors. That said, I don’t doubt how much worse things could be had I ended up in the hands of a bad doc and I’m very sorry that you had to go through that.

  • JR

    Reading this again, it sounds like the complications would have happened anywhere, because it was a problem with the pain-relief which was the same as what would have been given in the office.

  • http://www.bariatrichelp.wordpress.com Swimbikerun

    :) swimbikerun and eat healthy and you have less need of docs. ;) No offense to any one here.
    I’ve seen that one before, heard of it. I am sorry and embarrassed about it. We have docs who bike, run, and swim. They are too.
    I have never ever heard of that though, but I would spend my time talking more about the doc and posting notes and telling others your experience. It seems enough that once people start to see this man/woman for what they are and then don’t give their money to him/her.
    I hate to say that. :(
    You do the same.
    Not really as not all the teaching hospitals are a good thing. I’ve seen them with residents running the ER and some of them need to have learned more before they get sent out to ER’s.

    • DoubtfulGuest

      Maybe I understand about the teaching hospitals…I had a bad experience at one, and then a great experience at a different one, where I still go. I was thinking that sometimes, they’re more likely to set aside previous docs’ opinions of us so they can do their own thing. Sometimes. But a good private practice doc could do the same, so my statement wasn’t helpful, sorry.

      I’m caught in a strange mix of genuine empathy for my previous doctor and some weird form of traumatic bonding…that I’m aware of but don’t know what to do about it. Like Stockholm Syndrome, kinda, but I’m not being held hostage. I talk about it here a lot, but not by name. I don’t want to hurt his business, because he’s having trouble staying open anyway. His practice is mostly Medicare/Medicaid, and I have reason to believe he does a good job for most of those people. I already accidentally dinged his practice pretty badly, just by attempting to get the facts about my situation. I didn’t make anything public…long story but I was startled at how easy it actually is to hurt a doc, whether or not we’re trying to.

      This is not to say anything against what is right for your situation. I think in some cases your approach is the best one. I hope everything gets better for you soon.

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