Dr. Ian Malcolm, the gibbering mathematician played by Jeff Goldblum in the 1993 film “Jurassic Park,” is arguably best known for his oft-quoted line: “Life finds a way.” The line, uttered ominously to the team of geneticists who have successfully cloned dinosaurs for use in an amusement park, is a personification intended to suggest that nature will override any attempts by presumptuous human beings to control her. That is, nature will get what she wants no matter what measures are affected to slow her down.
Nature, it seems, has a lot in common with profit-based health care. As Elisabeth Rosenthal wrote yesterday in the New York Times, many doctors, when faced with increased regulation limiting the ways patients can be billed for services, get shamelessly creative in keeping revenue streams flowing.
Take, for example, the practice of “surprise charges” on hospital and doctor bills. As various health care reforms take effect, and in anticipation of others scheduled to be implemented, many insurers have slashed reimbursement for many medical services. To combat this and the consequences such measures have for their pay scales, many doctors are using the expertise of out-of-network providers during surgical procedures, as well as over the course of other forms of medical care, without patient consent. The practice is usually justified to patients and insurers as medically necessary. The reality is that, often, the job such an out-of-network provider is called in to perform is one that could be performed by a nurse or resident at no additional charge.
In one of the more egregious instances, New Jersey resident Patricia Kaufman was billed an additional $250,000 for a surgical procedure on her back after a pair of plastic surgeons were called in to suture an incision. In Kaufman’s previous procedures at the Long Island hospital where she had been receiving treatment, residents had been tasked with suturing.
In the case of Peter Drier, who had surgery to repair a pair of herniated disks in his neck, an unanticipated bill for $117,000 was issued, one which had appeared on none of his consent paperwork that he’d pored over prior to the procedure. The bill, from a neurosurgeon Drier doesn’t remember ever having met, was to pay for the assistance of one Dr. Harrison T. Mu. It appears that Drier’s insurer was expected to subsidize the contraction of a fully trained doctor such as Mu to perform duties usually relegated to in-network health professionals.
It might seem reasonable to some that reliance on out-of-network personnel was deemed necessary in relatively complex procedures like Kaufman’s and Drier’s, even when it is acknowledged that out-of-network providers charge 20 to 40 times more than in-network equivalents. The risks of spinal procedures can be high, and what is the lay opinion of a patient when set against the medical expertise of a neurosurgeon when quality of life, even life itself, are on the line? This is exactly the attitude many doctors rely on in utilizing these “surprise” methods, and the justification used when forwarding a bill to a patient’s insurer. Couple this typical perspective with the byzantine nature of medical billing – multiple bills from several different providers for the same procedure, and each bill riddled with obfuscating medical and coding jargon – and cynicism is not a requirement in understanding why these practices have been allowed to become widespread.
The practice isn’t restricted to the operating room, either. Mark Sullivan, who had emergency back surgery last year, was treated to a bill that included claims from 10 different providers, many expecting to be paid for services to which Sullivan did not consent to or even receive. For instance, listed on the bill was a $679 charge for occupational therapy related to a device designed to help Sullivan put on his socks, a device that Sullivan never used. Dr. Abeel A. Mangi, a Yale cardiologist, suggests that this is one of the ways that hospitals and doctors have attempted to make up for lost revenue. “There’s been a mushrooming industry of mandatory consultants for services that neither doctors nor patients want,” Mangi says. This includes occupational therapists, as opposed to nurses, helping recovering patients to use the bathroom, and dermatologists deployed to make initial consults on a rash instead of the normal on-duty physician.
These practices are, in part, a result of the increasingly litigious nature of healthcare. Doctors and hospitals will make overkill standard in an effort to stave off lawsuits. They are also, and perhaps primarily, motivated by profit. As the base salaries of specialized doctors decline, consultants have advised the use of “innovative” coding in billing patients for their care. Thus, the typically elective use of a plastic surgeon to close an ordinary incision is deemed necessary, and usually without the knowledge of the patient who will end up paying the bill.
The reason such opportunistic chicanery has been successful is that it is so difficult to regulate. On the ground floor, insurance examiners are never present at the procedure in question, so whether the use of out-of-network providers was necessary is almost always taken at the word of the doctor filing the compensation claim. At the institutional level, there are few regulations in place requiring hospitals and doctors to provide in-network care whenever it is appropriate and available. Lab work, X-rays and specialized care can be contracted out with relative impunity. Add to this the lobbying forces behind the multi-trillion dollar healthcare industry, and affecting change approaches impossibility.
Rosenthal, the author of the New York Times article as part of her ongoing “Paying Till It Hurts” series, believes that patients, current or potential, need to be informed and active in reforming the way the U.S. manages the health care of its citizens. In an interview with NPR last year, she explained that, “copays and deductibles are going up, and the nation — because it pays for a lot of medical care and subsidizes a lot of medical care — just can’t afford the way we’re doing this anymore.” That this is so is reducible speaks to the fact that American health care in general operates as a profit-based industry, she contends. Maximizing profitability simultaneously retards practical innovation and opposes standardization that would ease medical costs. “At some level, at a business level, you want your brand distinct, and you want to keep people in the universe of your brand. In many ways, it’s a business decision as much as a medical decision.”
This is no different in the case of “surprise charges” and the use of unwarranted and unneeded expert care. If Drier’s surgery had been billed as if he were a Medicare patient, Mu, the neurosurgeon that charged the $117,000 for his assistance during the procedure, would have been entitled to no more than 16 percent of the primary surgeon’s fee. That would have shook out to around $800, or less than 1 percent of what Mu expected and was ultimately paid by Drier’s private insurer. That this was not the reality results in the financial hardship of Drier, and every patient like him, either through the direct bill or increased premiums.
Advocate groups and lawmakers are already aware of the problem, and some states have begun composing laws designed to protect people against “innovative” billing practices. In New York, for example, the “Surprise Bill Law” is being considered, and if it passes it would severely restrict billing for out-of-network charges and any out-of-network procedure shown to be unwarranted would be billed as if it were in-network. Legislation is slow, however, and it does little to mitigate the financial crises faced by recovering patients who have been slapped by five- and six-figure charges they never expected.
Such laws, if passed, would appear to be significant safeguards moving forward against the greedy and convoluted machinations of the American profit-driven health care industry. Although Dr. Malcolm might have something to say about that.
