The US healthcare system, while flush with cash, is engineered and maintained by political decisions and figures that appear morally bankrupt.  Unfortunately, the only people actually going bankrupt are healthcare consumers without significant financial means or great insurance.

You don’t have to google far to find zillions of stories, but here’s just one from The New York Times.

A few months ago I wrote about the costs, and outrage, I incurred over some of the costs I experienced when one of my kids received “planned” outpatient imaging.

While we’ve used the healthcare system plenty in the past few years, it took a simple clinic visit to spark my ire to the same levels I reached a few years ago.

Old Man Soccer

A few months back I joined a men’s 40+ soccer league (I’m 37, but apparently I qualified based on my fitness level).

During the final match, running full speed to try to control a blocked shot, one of my fingers smashed into an opposing player’s chest.

I’ve broken fingers before, and at first I was worried I did again.  By bedtime it felt good and I thought I escaped the worst.

Wrong — I woke up with it swollen, bruised, and with poor movement.  I was starting a string of 4 ED shifts, so I pulled out an old finger splint from my nightstand (as I said, not my first broken finger) and went to work.

During one of my ER shifts I surreptitiously used our x-ray fluoroscopy machine to obtain some images. I was worried about a fracture so showed them to an orthopedic surgery resident wandering by.  He examined my finger and x-rays and told me to see an orthopedic hand surgeon.  He was worried I may have torn a ligament.

Less than ideal news.

While I am not a surgeon, my right middle finger is somewhat necessary for work and life.  Also important for giving people the finger.  The prospect of prolonged immobilization (or therapy or surgery) was not comforting.

Walk Right In!

My employer has an orthopedic/sports medicine clinic located not far from my home.  It’s advertised for evaluation of sports or other minor injuries, and calls attention to the availability of on-site x-rays.  Walk right in — no appointment necessary,

So I headed on down on a Saturday morning (Rogue Three in tow) and saw the doctor.  I was hoping one of the orthopedic surgeons would be bored and working on a Saturday, but alas, no.  I did see a highly qualified sports medicine doctor (who has worked with professional sports teams).

The cell phone snapshots I took of the fluoroscopy photos of my finger were not deemed sufficient, so he obtained regular x-rays of my injured finger.  It showed a fracture, but he was concerned about a possible tendon injury (not a ligament).  His specific concern, a central slip injury, could require surgery, and has a very long recovery time.

He said I definitely needed to see an orthopedic hand specialist.

So 2 days later, after a night shift and with 2 hours of sleep, I went back to the same clinic to see the hand specialist.

The swelling had improved, as had my mobility.

He confirmed (using the original x-ray) that I had a fracture. Thankfully the swelling and mobility had improved and he said there was a fracture, but no other injury.  It should heal fine, and I didn’t even need to follow-up unless I felt it necessary.

The Reckoning — The Bill Arrives

I finally received the bills for these visits:

1. A bill with the charges for both doctor visits.
2. A separate bill for the cost of the x-ray.

The radiology services offered inside the clinic are not owned/operated by the physician group.  The physicians are employed by a university (same one as me); the radiology equipment/personnel are owned/employed by a separate healthcare system that is affiliated with the university.

This situation is  quite common, and leads to significant confusion.  In some cases, it leads to massive bills.

It’s possible to go to a single place, receive bills from multiple groups, but have one of them be out-of-network for your insurance.  The result is a massive out of network insurance bill when you had no idea and often no choice (such as in some ERs).

This practice is common enough that some states are considering legislation to prevent it.  That is not the case here  — all my bills were from in-network providers.

Which of the first two bills do you think was higher? 

The combined bill for a visit to see a sports medicine specialist (who has provided care to NFL players) and an orthopedic surgeon with special training in hand issues?  Or the two pictures of my right middle finger?

If you guessed the x-rays, you are right!

The combined cost to me for the doctor is $240.  The cost of the x-ray is $280.

Yes, $280.  Not that the $240 was cheap — but you could at least squint your eyes and make sense of it.

Neither includes what will likely be a third bill — a radiologist interpretation of the x-ray — that hasn’t arrived.   While the sports medicine doc and orthopedic surgeon are experienced enough to interpret their own finger x-rays, it’s automatic that a radiologist reviews every image, regardless of whether the ordering doctor needs/wants the review. This is standard pretty much everywhere.

I have decent ability to interpret x rays as part of my training/job, but a well-trained radiologist has expertise far exceeding mine.  While it’s not always helpful — such as in this case — I don’t think we’re going to have the option to decline their review anytime soon.  Most physicians want radiologists review of every image, even if they are comfortable with reviewing images, because it makes our jobs easier in numerous ways.

Cue the Outrage

I know (or thought I knew) based on my experience and knowledge of the healthcare system, that a xray should normally cost under $100, and in many instances under $50.  I knew given where I was obtaining the x-ray, that the cost would be on the high end.  I was still caught off guard by the charge.

If you hadn’t guessed where this was going, I was not happy with the bill.  I hoped it was an error; or perhaps they had charged me a “facility fee” — a common way for clinics that are affiliated with hospitals to upcharge you (by being “attached” or affiliated with a hospital, they can charge you like a hospital).

Nope.  This is the contractually negotiated insurance price between the imaging center and the insurance company for an outpatient finger x-ray.  The actual charge for the x-ray was $380, discounted to $280 because of my insurance.

We’re on a high deductible health plan — in our case the right financial decision (which I’ve written about before).  We haven’t met the deductible, so for now we pay 100% of the costs until we meet our deductible.  So while I know we will get some big healthcare bills, it also means I am price conscious.

I’m fortunate that I have more financial means to absorb such things, but partly because we plan for it.  We max out our HSA every year, and have money saved that can pay for out-of-pocket medical expenses when needed (not an inexhaustible supply, but enough).

I called the billing department, loudly complained, and was told that my concern would be “noted” but not read by anyone because “price is not a valid dispute.”  You can imagine that did not go over well with me.   I went up the chain and spoke to a supervisor.  He also noted my complaint and said he would talk to someone about it, though I’m not sure what if anything will happen.

I also price shopped.

What Does An X-ray Cost?

I obtained three prices: two from stand-alone imaging centers, and one from our biggest competitor, another large healthcare system.

1. The Big Competitor — I called the imaging centers of another big healthcare system in our area.  They were clueless.  They told me $500, which I knew was b.s., so told them to try again.  Eventually they gave me a number to call, and after being forwarded around, ended up on a price transparency phone line (which is nice, except not advertised anywhere).  Cost?  $115 negotiated w/insurance, but 15% off if paid in full up-front.
2. Imaging center #1 — all they do is imaging; not part of a healthcare system, so should be cheaper given lower overhead and more efficient in delivering just one type of care.  It took asking a couple of people before they could tell me. Cost? $69, before insurance or self-pay discount.
3. Imaging center #2 — on the front of their website you can pick the exam and insurance (or self pay) and it gives you the cost.  Immediately.  This is AMAZING because of how foreign this in healthcare.  It’s nearly impossible to figure out the cost of something up-front.  We continue to take this for granted everywhere else in our lives, but continue to be sheep, herded along by the healthcare industry when it comes to medical care.  Cost? $40.  That includes the cost of having a radiologist interpret the x-ray.  It’s almost impossible to get pricing information this easily in healthcare.  Which is the problem.

Please note that for a finger x-ray it’s unlikely there is a difference in quality of the images or radiologist skill across centers.

How Much Is $280?

No, $280 for an x-ray will not break us.  It doesn’t mean it doesn’t impact us.  The extra ~$150-200 we are paying for my xray goes a long way.

Understand — I’m not crying poor.  But being a doctor does not mean I throw money away or just shrug off price gouging.  Every dollar has an opportunity cost.

$200 is a couple weeks of groceries (family of 5, 3 boys).  It’s two really nice date nights with the wife.  It’s my cell phone bill PLUS my electricity bill this month.  It’s the cost of a new car seat for Rogue Three (we just had to buy him two new ones).  It’s our annual donation to a foodbank.  It’s buying food for the ER staff for 4 night shifts (I usually buy pizza for everyone during night shifts once a month).

The opportunity costs are almost certainly much higher for my patients.  For some, $200 may mean avoiding eviction, or the electricity being shut off, or their kids having shoes without holes and a winter jacket, or eating real meals instead of fast food.

Straight to the Top

A few years ago, when perturbed about the cost of an ultrasound for my son, I emailed the hospital president.  I ended up talking with her in-person.

This time I emailed the CEO of the entire healthcare system to express my concern.  Time will tell if the email is ever read.

It was not a complaint about my bill — I can and will pay it (though if they knock a few $ off I won’t mind).

It was an expression of alarm in how our system is a set up to financially harm our patients.

Working in an ER, by necessity I have to order x-rays.  I’m relatively judicious in my use of tests, as I try to be conscientious of unnecessary radiation exposure (a big deal in kids), the conundrums caused by ordering a test you didn’t actually need, and the actual cost to families.  Sometimes you don’t have a choice — sometimes patients need a specific test or medication.

Yet even I was not aware of the x-ray costs at my own institution, which is operated by the same healthcare system that did my finger x-ray.

There have already been studies that demonstrated simply showing doctor’s the cost of a test in many cases will make them less likely to order it, without impacting patient outcomes or quality of care.  When I met my hospital president a few years ago, I discussed whether we could do something like this in our EMR.

She thought it was a great idea, but alas, nothing has come of it yet.  We’re due to have a new EMR being installed in 3 months, so opportunity is again calling.

While I think the CEO may reply to me, I’m not naive. I’m reasonably well-versed in the tenets and history of the US healthcare system, which is for all intents and purposes, broken on purpose.

While that is not the fault of the CEO, he does have influence.  While our system is broken, change will not happen by sitting idly by.  I will maintain some optimism that change is coming, but sometimes you have to get off your butt and push people to make change.

Change also has to happen on the individual level.

I would urge any of healthcare consumers out there to keep these stories in mind — ask your doctor about cheaper alternatives to receiving the same care.  Not every MRI needs to happen at the Ivory Tower (academic hospital) MRI suite — some can be performed at the dedicated MRI imaging center down the street. Not every lab needs to be in the hospital lab that runs 24/7 and also runs esoteric tests you’ve never heard off — plenty of them can be at the dedicated lab down the street.

I’ve already made the decision that going forward I will avoid obtaining my own x-rays or labs at my own institution when possible.

When treating patients in my ER, it’ll continue to make me even less likely to order a test “just in case,” an urge that hits almost every doctor at some point. Sometimes it’s for good reason, but sometimes it just harms the person on the other end.