Health care sticker shock

I HAD A minor stroke in April. Then I saw the bill and nearly had a heart attack.

For a trip to the emergency room, admission to the hospital for about a 36-hour stay, multiple imaging studies of my brain and nervous system, and a couple follow-up visits with my primary care physician and a specialist, the total came to more than $20,000. But that price is only the suggested retail price. My health insurer agreed to pay about half that, with my responsibility being $2,000.

The incident offers a unique opportunity to drill down into the opaque process of billing and cost-sharing in health care among all the involved parties — provider, payer, and patient—without worrying about permission or confidentiality because the information is mine. The goal was to decipher bills that seem designed to confuse with charges, allowed charges, bundle pricing, and deductibles.

“We’ve been talking about the perplexity of medical pricing since we were all able to talk,” says Barbara Anthony, the Pioneer Institute’s senior fellow in health care and a former state consumer affairs undersecretary. “The provider and the carrier have their own language in communicating. We’re on the outside of that circle. We should be in the center of that circle.”

My episode began on Saturday, April 18, when after dinner my wife and I sat down to watch the movie Olympus Has Fallen. Throughout the two-hour takeover of the White House by North Korean terrorists, I had trouble focusing my eyes and alternately shrugged it off to new glasses I wasn’t used to yet or the angle I was watching the TV from on the couch.

At the end of the movie, I stood up and immediately knew something was seriously wrong. I was seeing double, experiencing dizziness, and feeling disoriented. I told my wife she needed to take me to the hospital. Once we arrived at Beth Israel Deaconess Hospital–Plymouth, I explained the symptoms and was immediately wheeled into the emergency room to begin the testing protocols used to determine whether a patient is having a stroke and whether it is ischemic—caused by a blood clot that needed to be quickly dissolved—or hemorrhagic—caused by a burst blood vessel that ceases blood flow to various parts of the brain.

About 800,000 people a year are admitted to hospitals for strokes. About one in five people who have strokes die. Research and treatment have advanced to the point that if medical care, including clot-dissolving drugs, can be administered at the onset of a stroke, the effects can be minimized and patients have a much better chance of recovery.

Within an hour of checking in, two CT scans, an X-ray, and physician tests determined I did not have a detectable clot, so a clot-dissolving drug was not given. The doctor determined, however, my left eye was not “tracking,” meaning while my right eye was able to follow his finger, my left eye barely moved, thus causing the double vision. He determined further tests and observation were required and I was admitted to the hospital. Thus began the $20,000 odyssey.

On Sunday morning, I was taken for an MRI and then, several hours later, brought for a second MRI, with an injection of dye to study the contrast and find the source of the problem. That meant that within 16 hours of being admitted to the emergency room, I had undergone an X-ray ($176), two CT scans ($5,358), and two MRIs ($3,807), according to billing data I later received.

The neurologist overseeing my care came to my room after the last MRI to say she and the imaging technicians thought they saw an “anomaly” in the test indicating a “small stroke.” She said she wanted to order a third magnetic resonance imaging test to confirm what they saw but I declined. The doctor took my refusal as worry over radiation exposure and assured me the MRI used magnets, as the name implies, not radiation. But when I told her my concern was the expense and the impact on health care costs overall, her response was one that providers have offered for years. “You don’t have to worry about that,” she said. “Your insurance pays for it.”

Several weeks later, the bill I received from the hospital did not provide detail for the stay, just a general breakdown of the services by category. I called the billing department and was sent an itemization similar to what is submitted to my health plan, a breakdown not normally given to patients unless they request it.

According to the hospital, the total cost of the treatment between emergency room and in-patient care was $13,797, including $295 for pharmacy and $429 for the room. In addition, the doctors, who are not employed directly by BID-Plymouth but rather contracted through a Harvard physicians’ network, billed separately for another $3,953. Another $2,687 was billed in aftercare visits to my primary care physician; a neuro-ophthalmologist he referred me to; and Massachusetts General Hospital for another X-ray, bringing the total to $20, 437.

The providers appear to be forced to eat about half of their charges. My insurer, Harvard Pilgrim Health Care, allowed a total of $10,511 to be paid to the hospital and various physicians. Because I had not been to a doctor or hospital at that point in the year, I still had my full deductible to pay, which meant I was responsible for $2,000, with Harvard Pilgrim sending checks for the remainder.

Harvard Pilgrim’s explanation of benefits was impossible to decipher. The bill from BID-Plymouth equaled the Harvard Pilgrim total, but the details on specific service charges did not reconcile. In the line next to room and board, for instance, Harvard entered the hospital charge of $429. Then, under pharmacy, the carrier entered $13,368. The entire pharmacy charge was denied but a charge for $6,542 was entered for the room, meaning, to the uninformed consumer, that the health plan paid 15 times what the hospital billed for the room and nothing for pharmaceutical items.

Harvard Pilgrim officials say they pay a contracted bundled price for all the hospital services associated with stroke care—$6,543 for cases such as mine—and then enter that amount for a single service, in this case the room and board charge. The remaining $3,500 was the contracted price for the various physician and imaging technician services. For instance, the emergency room doctor billed $531 but was paid $348 by Harvard Pilgrim, while the technician administering the electrocardiogram submitted a bill for $50 but was paid the contracted price of $11.49.

There are a few things I learned through this endeavor that could be helpful to future patients. The bundled price for my episode was set and whatever care I declined in an effort to save my plan—and in turn, me—money, such as refusing the third MRI, did not affect my costs or the bundled-price reimbursement of Harvard Pilgrim.

In addition, comparison shopping for health care while being rushed into the emergency room is impossible. “You got your life in your hands. I don’t think you can really be the consumer at that point,” says Jason Radzevich, chief financial officer for BID-Plymouth.

Second, the billing and payment process is mired in byzantine methods that do little to help consumers understand what is being paid for and why. Part of the shock comes in seeing the enormous disparity between what the hospital bills and what insurance pays. “You can’t make apples to apples,” says Radzevich. “For you to sit there and try to make sense of it, you never will.”

Radzevich says hospitals are required by law to bill everyone their list price even though reimbursement is based on individual contracts between hospitals and health plans. The list price is collected in less than 3 percent of cases, he says, typically when the patient has an out-of-state insurer and Beth Israel is not part of their network.

There was a glimmer of hope, though, as Harvard Pilgrim officials, after meeting with me, agreed their explanation of benefits needs to be more accessible to customers, especially as more and more of them are required to cut a check beyond their premium payments. It’s no longer enough, they admitted, to expect people with deductibles to just pay their share based on what the health plans say.

Joan Fallon, Harvard Pilgrim’s director of communications, says change is coming as more consumers “with skin in the game” start to calculate where their deductible goes and as the state steps in to make the system more uniform. “This sort of billing is not unique to Harvard Pilgrim or to Beth Israel,” she says. “It’s just sort of how it’s done.”

Lastly, it’s fair to ask if an informed consumer really matters, especially when bringing up the rear in the fight against spiraling costs. Anthony, the former consumer affairs undersecretary, says knowing the costs upfront and controlling them beforehand is the optimal approach. Nevertheless, she says, it is the patient’s right to know how much he is being charged. The idea that bills are incomprehensible and it’s always been that way is, to her, unacceptable.

“The market should be driving this. I don’t see health care taking the leadership. Do we have to have a law to do that?” she asks. “Why do I even have to defend a consumer’s right to know what they are paying? I don’t have to argue with any other industry that consumers have a right to information about cost.”