Taking Back the Ship

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altSteve Lopez, a columnist for the L.A. Times, recently reported a classic tale of medical care sticker shock. A man brought his daughter to an emergency department, wanting to check to see if she had appendicitis. She didn’t. The bill for answering that question was almost $5,000.

Steve Lopez, a columnist for the L.A. Times, recently reported a classic tale of medical care sticker shock. A man brought his daughter to an emergency department, wanting to check to see if she had appendicitis. She didn’t. The bill for answering that question was almost $5,000. The emergency physician’s fee for taking the history, doing the physical exam, interpreting the laboratory exams and X-rays, and making the diagnosis was $309. The hospital’s charge for the bed, supplies and nursing staff was $1,288. The pathologists fee for “supervising” the lab that ran the blood tests was $540. And the charge for the CT scan and the fee for the radiologist to take the two minutes to read the scan cost was . . . I’m too embarrassed to say.


As we all know, this story is far from unique. Lopez reported the story of another patient who had a bone spur removed at an outpatient surgery center. Her total time in the facility was five hours. Total bill? $37,000, not counting physician’s fees.

But high charges are only part of the story. The truly strange part is on the other end: almost no one actually pays these exorbitant amounts. In the first story, even though the little girl’s father had a policy with a $5,000 deductible, he still benefited from the negotiated rates of the insurance company. So the $1,288 hospital fee magically dropped to $683. In the end, he paid about $3,000. Other people have discovered that if they either claim to have no insurance, or really don’t, they still pay less – sometimes a lot less. Lopez tells the story of a patient and his brother-in-law who each received MRIs of the shoulder. The first man paid in cash and was charged about $350. The brother-in-law used his insurance and was charged $13,000, with $2,500 being his out-of-pocket portion. And then there was the case where Kaiser – you know, the insurance that the Affordable Care Act took as a model for the Accountable Care Organizations – was charged $7,500 for one of their insureds colonoscopies. For some reason, they only paid $470, and the patient paid $15. The rest of the bill just went away.

Between outsized charges and wild variability of payment, it’s no wonder that the government wants to bring health care under one roof. If nothing else, it would bring a much-needed consistency to the system. Don’t get me wrong. I don’t support a government run health system, for a variety of reasons related to quality and cost. But there is one thing that we as physicians can no longer deny. The cost structure for health care in America is screwed up. There is no correlation between the price of the care and the quality, necessity, time, or risk involved in the provision of that care.    How did we get into this mess?


First, we started with a system that lent itself to greed and inequality. Back in the good ‘ol days when doctors made house calls, if you couldn’t pay the doctor or hospital, you might get care – if the doctor was motivated by charity – but you might not. Doctors are still just people, and while some doctors would work for a chicken or a pie, some would not. Hence the proverbial ‘billfold biopsy’ – a quick peak in the wallet before allowing a patient through the door. Of course, even from the beginning, we tried to provide necessary health care to the elderly and children. It was the least we could do for the most vulnerable members of society.

Then a few things happened which began to spike the cost of care. First, medical care itself got more advanced, more specialized, more expensive, and people started to live longer. Then, the public mindset began to shift to seeing medical as a right – something to be expected, even demanded. Finally – and this may be the most critical ingredient to the explosion in health care costs – through insurers, patients became insulated from the cost of their care. Employers began paying for insurance without patients ever seeing the cost, and medical providers began charging insurers without the patient’s input. All of a sudden, the system was in place for a positive feedback loop, amplifying costs without appropriate accountability. More patients were requesting more services from more providers, who were now able to provide more sophisticated and more expensive care. All the while, there were few, if any, disincentives for any member of the chain to increase prices. Within a few short years, the cost of the care being covered by insurance, whether it was Medicare, Medicaid, or private insurance, began to skyrocket.

Insurance companies tried to slow things down a little by being sluggish. Medicare paid on last year’s fee schedule. But doctors are no dummies; we started adjusting our fee schedules upward to account for the delays. The indication for procedures grew more and more liberal, and the spread between what we charged and what we would accept grew larger and larger.

And just in case you were in the camp who tried to pare down the tests you ordered or the procedures you provided, there were the lawyers to contend with. They advertised to anyone with a bad outcome that they “could be entitled to compensation”. So doctors just went with the flow, ordering tests and letting charges mount. Patients got more of what they wanted, the insurance companies made a bundle, and we didn’t do too badly either.


But then we started to see the rocks we were about to hit. Not all of those CTs, blood tests, medications and procedures were actually helping the patients. Excessive radiation caused cancer. Unnecessary testing led to unnecessary surgeries, and drugs of questionable value were being sold for exorbitant costs. It began to become evident that the ship holding the future of our children and grandchildren was headed for a financial catastrophe.

When we were finally fed up and looked around for someone to turn the ship, we saw that we are the ones at the helm, calling for more sail.

Those of us who have complained about the government’s hapless attempts at healthcare reform have to admit that at least they are doing something. Granted, their efforts could very likely make things worse, but they are trying something. But there’s only one group of people really capable of turning this ship around, and it’s us.

How can we do this? Where do we start? First, we have to be willing to be honest about what is truly necessary for quality care. When we see excesses – and we will see many as we start to look around – we have to have the courage to speak up. We need to get involved in our billing – both our own groups and hospital-wide – to bring sanity, transparency, and fairness. I have said this before, but emergency physicians have always been leaders in providing cost efficient, high quality care. We need to continue to hold this line, and begin to do even better. We will need to hold our colleagues accountable, which will not be easy. We need to advocate for fairness, transparency, and accountability in the system of insurance. And we must bring some sanity to the system that provides compensation to the victims of true medical mistakes.  It makes no more sense to pay an attorney 40% of a malpractice award than it does for me to charge a man 40% of his life’s earnings after saving his life.

You can be sure that this isn’t going to be easy.  Some will even say that it is impossible to bring this system back to a healthy balance.  But I say that emergency physicians do this every day.

Mark Plaster celebrates 20 years of chronicaling night shifts in this column.
Tell us about your most memorable night shift 

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