By Bob Litton
If you were concerned that this might be an essay full of statistics, don’t be. I never had a good relationship with numbers. No, this will be mostly first-hand experience and concrete observation.
Is there anyone is this nation (the U.S.A.) who is unaware that medical costs have gotten out of control and that other problems related to medical care (e.g., unnecessary exams and treatments) besiege us? Very few if any, I would assert.
From personal experience, I confidently declare that spiraling medical costs began in the mid-1970s. It was in 1977 that I bought my first and only health insurance policy. Up until that time, I was either in the service or attending a university where clinics were available to me at no cost, or I was working for a governmental agency which covered me through group insurance. In 1977, however, I was working at a small newspaper in West Texas, and my medical care was totally up to me. So, I bought into a fairly inexpensive policy with what turned out to be a most reliable company, as I discovered shortly thereafter when I slipped on some ice and broke an ankle.
Not many months after that, I received notification from the insurance company that they had sold their hospitalization coverage to another company. The next premium notice I received, from the new company, was the same as what the first company had charged. However, the next premium notice was half again as much higher. I could not afford that premium, so I dropped the policy.
Subsequently, I had a few minor physical problems for which the doctors’ bills were tolerable enough for me to pay them out of my pocket. A couple of major dental problems were more expensive, but the good doctors let me pay them in a few installments.
Later, I learned that, since I had a ten percent service disability, I was entitled not only to VA treatment for my disability but also other medical services the VA provided. As long as I lived in the Dallas-Fort Worth metropolitan area, I was fully covered medically. However, when I moved out into the remoteness of the Big Bend country, I noted that the nearest VA clinic was sixty-six miles away and the nearest VA hospital (with limited services) was two hundred and five miles away. That was a risky situation, yet I vowed to live with it and hope for the best, for the madness of Dallas had grown intolerable. (Even just between Dallas and Weatherford, sixty-one miles to the west, the highway activity was crazy.)
In this huge county where I reside now, with a small population of only about 9,300 folks, there nonetheless is a hospital. Originally operated by the county, it has been leased since October 1999 to a private management company for a twenty-year term with two options to renew for ten-year stretches. I was somewhat acquainted with hospital affairs from 2003 until 2011 because, as a reporter for the local radio station, I covered the hospital district. However, there is a great difference between the hospital itself and the hospital district. As I said, the hospital is operated by a private management firm, with its own board of directors, and its business is treatment of illnesses and injuries affecting everybody in the area; while the Hospital District is a board of five elected citizens and a three-person staff whose primary concern is supposed to be certification of indigent patients only and covering their medical bills. Other duties for the district are recruitment of doctors and maintenance of outlying medical clinics. There is, naturally, frequent interaction between the two.
My personal encounters with the hospital itself started one afternoon in 2008 when I felt a rhythmic pattern of constrictions just beneath the rib cage. Also, about every fifteen minutes I had to go to the bathroom and try to throw up, but succeeded only in dry-heaving. Finally, about 9 p.m., I called a VA nurse who said I could be having a heart attack and should go immediately to the nearest emergency room. She told me the VA would cover the expense, even though it was not a VA hospital, as long as I and the hospital abided by the VA regulations: I could stay in the hospital overnight if that was needed to stabilize me, but as soon as my condition was stabilized I was to be transported to a VA hospital.
I went to the emergency room, where the nurse checked my vitals and had me lie down on a stainless steel examination table. From this point, I cannot provide an exact chronology of treatments, but soon in the process I was given what the nurse called some kind of “cocktail”; no, that was not some alcoholic drink, it was just some other liquid mixture. Within fifteen minutes I felt much better and wanted to go home but did not know whether that was allowed. I called the VA nurse, and she told me I should simply follow the doctor’s orders.
Well, the doctor kept me on that table all night long, except for excursions to another room where I was run through a CAT scan and to another room where a technician x-rayed me. They also took a urine sample and a blood sample. And they examined me with EKGs at least twice. At one point the doctor made a lame apology for not attending to me personally often enough, saying it was a very busy night for the ER. Near dawn, he announced he was going to admit me to the hospital “for observation”. I should have jumped up right then and run home, but I was trying to abide by regulations, and I had told the doctor that I could be admitted for only one day: a comment intended as a warning but which he jumped on as an opportunity.
In a patient room later, I was examined by another doctor, who ordered yet another EKG. A half hour later, this new doctor returned, smiling, and said I had suffered an attack of acid reflux.
“That shouldn’t be, doctor,” I said, “because all I had for lunch was Chinese food.”
“Chinese food is one of the spiciest foods there is,” he said.
I had neglected to specify that it was moo goo gai pan, which, while very sauce-dunked, is not spicy, not at least at our local Chinese restaurant. Besides, I had begun feeling slightly uncomfortable before lunch. That doctor released me.
I was very angry as I left the hospital. It mattered not who paid for the exams and treatment; I imagined, probably correctly, that the doctors had managed to run up quite a sizable medical bill for the VA to pay. The next evening I went to the ER room to complain to that ER doctor, but a nurse intervened. I told her I should have been released much sooner than I had been and that they should not have extended those examinations so much after I recuperated following the ingestion of that “cocktail”. Oh, she was feisty! She said that if I had taken off without formal release, nobody would have paid the bill – “not the VA, not any insurance company, not anybody!”.
My second experience with our hospital occurred when I fell down one night while covering a City council meeting for the radio station. I wanted to follow a CPA who was leaving after submitting his audit and ask him some questions. Unfortunately, one leg had “fallen asleep” and when I tried to stand I crumpled to the floor, breaking my right hip and shoulder. I did not actually fall, just crumpled, which indicated to me that I have brittle bones. My shoulder break was clean and did not require an operation; the broken hip, however, did require an operation.
The EMT’s toted me out of the City council chamber on a stretcher to an ambulance and in it to the hospital, where, at the receiving foyer, I was photographed and obliged to sign (with a scribbled signature since my shoulder had handicapped me) several documents, the most conspicuous one being acknowledgment that I would be personally responsible for all procedural and care expenses, regardless of who else might be billed. I told the nurse and the clerk and the doctor that I had medical coverage through the VA and they should not bill anybody else. Moreover, several concerned friends who had also been at the City council meeting were present: I asked one of them to use my cell phone and call the VA’s hotline nurse, which he did. The clerk photocopied my VA card, all right, but along with it, she also photocopied my Medicare Part A card (I had not opted for Part B).
In response (really non-response) to my statements, the hospital personnel said something like, “Oh, we are only concerned with making you well again! We can’t waste this time talking about whom to bill.” The greedy and blind (or indifferent) nincompoops did not bother to pay attention to two important facts: (1) I had only Part A Medicare coverage and (2) I was completely reliant on my VA coverage, which would have been mostly adequate if they had bothered to bill the VA. Thus I have to assume that either they blindly assumed Medicare would cover more than they did; or they believed, on what basis I cannot gauge, that the VA is either slow or recalcitrant when it comes to reimbursing private medical facilities. Anyway, Medicare did pay for the partial hip replacement operation at least.
The air ambulance service is the only entity that bothered to bill the VA, probably because Medicare refused payment; it took the ambulance people nearly a year to collect their fee (which starts at $40,000 and rises according to the amount of medical attention the patient requires during transport). Ladies at the ambulance service headquarters phoned me every three or four months, starting when I was still in the hospital recuperating. In their always cheerful voices they asked me how I was doing and informed me they were still communicating with the VA, which they claimed was having difficulty obtaining information from the hospital(s). Finally, about a year later I received a joyful call from one of the ladies informing me that the VA had paid them.
About two years after that I had another experience with the hospital, one about which I cannot say much because I was completely out of it: I had had a viral encephalitis attack. Since this essay is already overly lengthy, I will refrain from giving the entire narrative of events: I have not much personal recollection of them anyway. I will start with a friend coming to my apartment to check on me at the request of a couple of other friends who had told him I was speaking bizarrely. He found me lying on the kitchen floor and called yet another friend who came over and helped him lift my heavy body onto my bed. Then he called for an ambulance. I was unaware of all of this. I do not know what they did at the local hospital, but my friend told me that after some preliminary examination I was carried by air ambulance to an Odessa hospital. My friend told me I was in intensive care for about three days and then was sent to the Alpine nursing home where, after a couple of weeks, I awoke aware of my surroundings. During the time I was “out of it” I apparently was able to walk and attend to my bodily functions normally, although I reportedly fell one day and broke a clavicle which engendered yet another trip to the hospital’s emergency room.
Of course, during all of the above activity the medical expense meter was running full tilt. After it was all over and I was home again, I got bills from individual doctors and notifications from Medicare concerning what claims they had paid and what they had denied. The doctors’ bills were particularly harsh, prominently showing as they did a sentence or two declaring that if I did not pay on time they would sic a collection agency on me. What happened to all those smiling faces uttering their assurances that all they cared about was making me hale and hearty? Thanks to a small inheritance from a maternal aunt, I was able to pay most of the individual doctors and labs either entirely or in monthly increments. However, by this time I had four accounts at the local hospital totaling slightly more than $31,500. I reached an agreement with the hospital to pay $25 once a month on each account: $100 total. After a few months of that, they suggested I apply for a “charity forgiveness” of my total debt, for they knew — at age 69 — I was unlikely to live long enough to pay off the entire debt, and they could write off my bill on their tax statement. I felt, as I wrote the request for debt forgiveness, that I was asking a robber to forgive me for not having enough money in my wallet.
I was irritated mostly by the itemized list of services showing charges for fresh medicines that the VA doctors had prescribed. I already had an adequate supply, which my friend had turned over to the hospital staff. Of course, the hospital’s charges for those same medicines were a good deal higher than what the VA had charged me. To give you some idea of the range of difference, the hospital charged me $25.20 for one 150mg Wellbutrin SR and $46.20 for two 20mg Prozac caps I was given. (I could have received a full month’s supply of either of those medicines from the VA for no more than an $8 copay.) Also, at each hospital to which I taken, my broken shoulder was given a new sling ($241.50 for one sling at our local hospital).
The reason for these fresh medicine supplies and repeated replacements of slings, I believe, is that a regulation or a rule among hospitals is that every need must be freshly supplied upon the patient’s entering. Part of this reasoning doubtlessly is that the hospitals and clinics do not want to be held legally responsible for a medicine or a device provided at another medical site. This is part of the overall policy of – to put it crudely – covering their asses. But another reason for it – one difficult to distinguish from the other – is that the policy also helps them make more money.
That is my tale of woe. Now comes the time to analyze its elements toward understanding why medical expenses have outpaced people’s ability to pay for them. Everybody – including the doctors, the lawyers, the insurance companies…and, yes, even the patients – has created this mess.
The doctors have contributed to the problem by making continual mistakes – the most infamous types being treating the wrong patient for a disease afflicting someone else or amputating the wrong limb or leaving a surgical sponge in someone’s abdomen. But I hold them also culpable for their arrogance and distance from their patients; how often have you seen your doctor in a local restaurant? But more pertinently, how often has your doctor allowed you to quiz him or her about their procedures or prescriptions? And did he or she listen to you when you tried to discuss who should be billed for your treatment?
Of course, a doctor’s own expenses are high because he or she has to pay nurses’ salaries, maintain high-dollar equipment and especially pay very large malpractice insurance premiums. Also, he/she has to make his/her own salary commensurate with his/her professional image: at least $100,000 a year. And then there are those patients who have not the wherewithal to pay him/her, and the law says he/she and the hospital have to treat them anyway. But often enough there is a small sign at the registration window saying something to the effect that payment is due the day of treatment. So, the doctor is trying to cover his or her own ass while also accumulating wealth.
The lawyers are at fault for all their commercials appealing to people’s greed. In their ads they claim that people who even suspect they might have suffered some debilitating effect from a particular medicine or who might have been physically harmed by poorly conducted medical treatment could possibly receive hundreds of thousands of dollars in compensation by joining in a class action lawsuit. The ambulance chasers must find such ads a lucrative way of building their business, because the ads are numerous and enduring…as well as nauseating.
The insurance companies are at fault, I believe, for having high premiums, high deductibles, and in some cases making it an arduous and perhaps a fruitless task for the doctor or the hospital to collect. I also believe they are at least partly responsible for the excessive use of CAT scans, x-rays and EKG’s as well as the redundant supplying of patients’ ordinary medicines and of arm slings. If any one item is not new and spotless, if every examination technique is not employed, they seem to feel, then they are open to potential lawsuits. And, sad to say, they are probably right.
Now, finally, for the patients – among whom, of course, I am one. Many, perhaps most, of us do not look at the list of medical charges, especially if we are largely covered by health insurance. And, as for high deductibles, they actually can have a positive as well as a negative impact: on the one hand they cause the patients to have a more sensitive role to play in their medical care, while on the other hand they can be so steep as to drive patients away from needed treatments. I believe that, if patients would look at those charges and note how minor medicines such as aspirin is billed for as much as $15, they would wake up to how ridiculous our health care system is. I should not ignore the greed of many patients either. Obviously many folks are responding to those ambulance chasers’ ads. Anything for a quick, easy buck!
We really do need to revamp our health care system, but there seem to be multiple blocks hindering any true reform: ignorance of the admittedly gigantic medical industry and lack of political will on the part of the politicians, disincentive from potential reduction of a lucrative field for lawyers, and lassitude on the part of patients who are too much comforted by those unreadable insurance policies and undecipherable hospital bills.
As for the insurance companies, I am not sure where they stand on reform. I tend to believe that they favor it, but they are under pressure from lawsuits to put pressure on doctors and hospitals, who in turn put pressure on patients. In other words, we are all guilty of contributing to this mess. But what can we do about it?
My modest proposal is frankly quite bizarre: I acknowledge that no one will ever adopt it. I would suggest that we set the president of the American Bar Association, the president of the American Medical Association, and the president of American Health Insurance Plans, as well as the smartest insured citizen in the country in a large room and lock the door. They may be accompanied by two assistants each. All of the room’s occupants are to be dressed only in their pajamas. The temperature of the room is to be set at 60 degrees Fahrenheit. A couple of other side rooms should be provided with cots (no blankets) so the conferees can take occasional naps, and there should be an attached bathroom with shower. Also, they should be fed regular, healthy meals. They are not to be allowed to exit until they develop a sensible health care plan for the entire population of the United States. The reason these folks have to do the job of reforming the health care system is because they are the only ones who understand all its facets. Congress is too ignorant, lazy and motivated by political considerations to take the task on handily.