OUR CONVOLUTED HEALTH CARE PAYMENT SYSTEM

By Cory Michael, MD

Three men walk into a deli for lunch, take a number, and sit quietly until called. There are no prices on display, nor is the food visible. The first man, Ron, is called to the counter and states that he is hungry when asked what brings him in. He presents his food insurance credentials, and five minutes later, he walks out the door with a 12-inch gourmet sandwich, a side salad, and a smoothie in exchange for a co-pay of $1. The following week, Ron’s insurance company sends him an explanation of benefits in which the deli’s charge for the food was $15, but the large size of the company allowed them to negotiate a price of $9. The remaining $8 was covered as a benefit.

The next customer, Bill, is called and presents with the same complaint. Review of his credentials shows what he is eligible for, a 6-inch generic sandwich and a bottle of water. He gets his food after twenty minutes. His co-pay is $3. The food is unsightly and unsatisfactory in taste. Bill leaves and pays cash for lunch elsewhere. His explanation of benefits later reads that the charged price was $10 negotiated to $7 by the insurance company, but only a $3 benefit is possible for lunch. The deli later sends him a bill for the remaining $1 even though his lunch was inadequate.

The third customer, George, waits thirty minutes until served. His food insurance does not cover primary lunch, and the deli initially refuses to serve him as a result. After some discussion, they agree that he can have a 4-inch mini sandwich and a water cup for a cash price of $15. Hungry, he agrees.

Ridiculous as it sounds, the scenario presented approximates the U.S. health care system, and I have actually been on the customer side of all three types of plans in addition to being uninsured for the first nine years of my adult life. My current insurance is a “mid-level” product similar to Bill’s plan.

Enter my latest health care issue: hypertension. My blood pressure crept up on me about a year ago, but it wasn’t until I sacked my internal medicine physician and opted for a nurse practitioner that I learned sleep apnea may be contributing to my elevated blood pressure, as I had been told that I snore horribly and sometimes stop breathing. I decided to test the possibility by sleeping in my hospital overnight with a pulse oximeter (oxygen monitor) on my finger with a nurse checking in on me periodically. To my surprise, my oxygen levels dropped down to 70 percent (normal is around 95 to 100 percent) during episodes of apnea (cessation of breathing).

I next sought out a continuous positive airway pressure (CPAP) device to remedy the situation and found one I liked for about $900 cash which I was willing to pay out of pocket so that I could start sleeping better as soon as possible. I talked to a respiratory therapist in my hospital who agreed to help me adjust the pressure setting.

Hold it right there. I couldn’t get the device without a prescription from a sleep specialist ($150 co-pay for the initial consultation and charge to insurance of an additional $45), sleep study (cost billed as $3,800 but negotiated by insurance to $900, $350 of which I had to pay out-of-pocket), additional physician consultation for the results ($15 co-pay with $60 kicked in from insurance), and then a rent-to-own plan for the device (another $400 from me/$600 from insurance; original “price” of $1,500 but available online for $850 cash). The sleep study addressed additional concerns such as restless leg syndrome, bruxism (clenching of teeth), and the loudness of my snore, none of which were concerns of mine. I did check the box on the questionnaire that I had problems with nightmares, but the physician said that she only treats sleep apnea.

If you are keeping track, yes, I spent about as much using the “appropriate” channels as if I would have if I had simply paid cash for the device. My insurance (and thus any of you who share my plan) also chipped in considerable extra costs among the red tape, not to mention the additional month I went without the CPAP. Suffice it to say that it became clear to me why people set up sleep centers. Perhaps there is a bit of humorous irony in a radiologist complaining about this, but it should be said that I am paid a flat salary by a hospital and make no extra compensation in the unnecessary exams that I interpret. I am well aware, however, that the hospital “charges” at least double the real cost of most procedural devices that I use. They can do that when there is no transparency, i.e. no price on the wall.

Regarding the “freedom of choice” we love so dearly, I had no choice at all in this encounter. The sleep lab, consultant, and CPAP were all chosen by my insurance company, the only company my employer offers.

Another point highlighted here is that the major benefit of health insurance is not what the company pays but what the company negotiates on your behalf. The charged price of the sleep study (the diagnostic test), for example, is more than double the cost of the CPAP (the treatment). In other words, this is one of those common cases in which the treatment costs less than the diagnosis. When people complain that Canada doesn’t have enough MRI machines, for example, they should also consider whether or not they actually need more.

Health care payment is indeed a system so confusing that the typical American — despite a robust thirst to complain about system modifications (I have even entertained rants from free clinic patients) — probably doesn’t understand his or her own health insurance. So true is this that when the Affordable Care Act attempted to eliminate plans similar to George’s above, Americans screamed in outrage. Among my own social circle, I found that some of those most likely to desire George’s plan were actually physicians who would rather gamble with their own health than pre-pay for basic service coverage (which is actually a tax shelter).

Since Americans seem to resist change no matter the cost, status quo seems to represent our foreseeable future. I suppose I should just be happy that the trumped-up concept of death panels hasn’t come to fruition lest my sleep apnea and hypertension make me ineligible for coverage. I should just smile and have a sandwich. Wait, I just realized that the nearby deli isn’t in my network.