We entered the hospital with great anticipation. Our baby was overdue and with no signs of delivery, I was admitted and was to be induced the following morning. Three days later our baby would be our greatest blessing on Thanksgiving Day.

It wasn’t until weeks later that we found ourselves scratching our heads over costs we incurred bringing our daughter into the world. We were fortunate to have had fantastic health insurance through my husband’s work, but even with sixty percent of the bill covered we were having trouble deciphering the hospital bill. Only in healthcare do consumers accept the terms of financial responsibility without question. Nothing of course was itemized. My husband, a high school math teacher requested, from the hospital, an itemized list that would explain the exorbitant costs. Even with his mathematical background the extensive list was just too daunting to wade through. There were pages and pages of items that we could not prove or disprove definitively. Everything imaginable was on that list-every single pill, gown, linen, toilet paper whatever.

Being young and green, we were hit with at least one bill that could have been avoided had we known. It was a mistake we did not make again with the next four kids, who were born in the same hospital and delivered by the same doctor. With the firstborn we failed to choose a pediatrician before she came into the world. Before her birth, one of the myriads of questions we were asked upon entering the hospital was the name of our pediatrician. It never occurred to us that we should have pre-chosen a doctor for our unborn child. ‘No matter’, we were told one of the ‘house’ doctors would look her over. We forgot about it until we opened a bill from one of the hospital’s neonatologist. The bill was outrageous. This doctor whom we had not met personally was a specialist and the bill reflected so. Additionally, because the neonatologist was out of our insurance network, we were forced to pay out of pocket. We recovered by the time our second child was due and we were wiser the second time around. Since that time we have made sure every expectant parent we knew.

We were married four years before our first child was born and enjoyed very good credit. Imagine our surprise, when following her birth we received a bill from the hospital stating that our account would soon be turned over to a credit agency for non-payment! We were shocked since it was the first bill we received. On top of that, my husband had made at least one visit to the billing department of the hospital for information on what we owed and find out why we had not received a bill. He was assured during that visit that everything was as it should be and we would receive a bill soon. Just in case, he paid $100.00 on the bill. It took many phone calls to straighten out the hospital’s mistake. Finally we were able to speak with the right person at the right time and the bill was adjusted with their apology. The hospital billing-associate also was able to flag the account to make sure that it was not sent to a credit agency. We were thankful to finally reach the one person who not only understood the system, but also listened to us.

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Ray Burow was a 2012 Costs of Care Essay Contestant. 

As a medical student, one quickly learns not to question the wisdom of authorities, and appropriately so. Do your work quietly and conscientiously and study hard. Take all criticism enthusiastically and graciously. Do not speak unless spoken to. Beyond the compassion and empathy we are all expected to champion, these are the proverbial medical student keys to success. In our roles as the lowest rung on the medical ladder, this indoctrination comes from a combination of both trial and error and, put frankly, fear. I was no stranger to the age-old horror stories passed down from one anxious student to the next about encounters with particularly hardened attendings.

I was told Sarah* had a clot in her left arm; as the sub-intern on call, it was my job to admit her to the medicine service. Sarah was quiet – super quiet – and curt in her answers to my attempts at open-ended questioning. The little that I did glean was that she had first noticed a bump in her left arm one month ago and now it had gradually enlarged, becoming tender. A month and a half ago, she had been hospitalized for pseudoseizures while on vacation in Puerto Rico. She apathetically denied every other question I asked, including about ten specifically intended to evaluate her clot risk. Aside from her left upper extremity exam, her vital signs, physical exam, and admission labs were all normal.

Ultrasound confirmed that she had a large superficial venous clot in her left mid arm. A quick online search refreshed my memory on the subject: superficial clots, when provoked, cause discomfort but do not require a large medical workup; unprovoked clots, however, are rarer and indicate risk for hypercoagulability. Sarah had denied all of the questions I asked about clot risk. Yet despite our half-hour long conversation, I remained unsatisfied with the small amount of information I had gathered. In standard medical student fashion, I returned to her bedside to clarify her history.

“So I know we talked about this before, but I just want to make sure. They did not get any blood from your left arm or hook you up to an IV when you were in Puerto Rico, correct?”

“Oh no, they did,” she replied coolly. “I had an IV in for the two days I was there. Sorry. Did you ask me that before? I guess I just wasn’t paying attention. I’m tired. I’ve been here a long time.”

With a provoked superficial clot, Sarah could be followed as an outpatient. Yet when I told the resident about this new development, she felt there was little she could do: the ER doctors had gotten a vascular consult and it was the vascular attending who had recommended that Sarah be admitted. Put mathematically, this is basically what happened:  Vascular attending > (ER attending = admitting attending = medicine attending) > resident > me. The powers that be had spoken, and I felt powerless.

She got therapeutic deep vein thrombosis treatment. There were progress notes, nursing orders, and thousands of dollars in lab work. We called in the weekend ultrasound tech from home to evaluate for clot extension.

I got to practice my communication skills when the resident let me call the vascular attending a day later to see what he wanted to do about anticoagulating the patient upon discharge since her clot had not extended. “What do you want?” He answered, reminding me of my place in the hierarchy. Was he the dreaded attending from those stories? I took a deep breath and explained that I did not think Sarah needed to be anticoagulated given the nature of her clot. “Are you kidding me?” He was angry. I was scared. “I explicitly asked the ER attending, and he told me it was unprovoked. God, she didn’t even need to be admitted. Discharge her, please. Now.” He hung up. I did as I was told.

Or at least I thought I did. Sarah’s name was still on my list when I went to round on my patients the next morning. Dumbfounded, I asked the resident if she had co-signed my discharge order as I had requested before leaving the day prior. “Oh my gosh, I totally forgot,” she said. My heart sank.

Sarah, true to form, had been too passive to say anything to her nurse. And yet why should that be her responsibility?

Despite everything we had done, we all had been too passive. Communication counts at every level, now more than ever.

*This name has been changed.

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Ms. Heney is a graduating fourth year medical student at the Warren Alpert Medical School of Brown University. She is looking forward to a residency in Family Medicine at Brown where she can pursue a career in academic medicine centered around caring for those in need. Her current research interests include refugee health disparities and teen pregnancy. 

Mrs. B was washing dishes in the kitchen when she heard a thump where her twelve-month-old son was asleep. She ran to him and found her son had fallen from a chair (code: e884.2). He was crying (code: 780.92) and visibly shaken, but did not have overt signs of bleeding, bruising, or trauma. She picked him up and immediately brought him to the emergency room. There, he was triaged by the nurse (nursing report #1) and vitals were taken (nursing report #2). Shortly after the mother and son pair settled into the pediatric emergency room, he vomited once (code 787.03). The emergency medicine residents came by an hour later to conduct a focused interview, and performed a comprehensive physical exam (code: 89.03). He took care to ask at least four elements of the history of present illness that included location, quality severity, duration, timing, context, or associated symptoms from the event. He performed a complete review of at least 10 organ systems and surveyed the patient’s social history (code: 99223). It was decided that the boy was to be observed in the ED for the next few hours for signs of brain injury or concussion. No labs or imaging studies were ordered. The nurses were instructed to check for vital signs every hour (nursing reports #3,4,5,6). During the observation period, the boy was found to be active, interacting well with mom, hungry, without signs of lethargy or focal neurologic deficits. When the attending physician came by to evaluate and assess the patient, he agreed with the resident’s report and signed the discharge note. The mother was given discharge paperwork and instructions for returning to the hospital if she noticed any new, alarming symptoms.

This is what Kelly, an emergency department medical coder, gathers while reading an ED admission note.  She turns to me and explains that the few lines of attending attestation are the only way the patient can get billed. Kelly types in “959.01” into her software because she memorized the diagnosis code for “head injury, unspecified.” She has been doing this for the last 18 years. As I listened, she explained that a head injury in a twelve-month-old infant is automatically a level three, so long as the resident documents a review of ten systems, past medical history, and a physical exam. These levels indicate the complexity and severity of the patient’s disease/injury. “It’s all about the documentation,” she says. “If just 9 organ systems instead of 10 are documented,  even a critically ill patient could be down-coded to a level 4.” In this case, the resident did not order any additional labs or imaging studies, keeping him at a level three.  Kelly then counts the number of nursing reports that were filed for this patient and enters the number. There are no specific codes for procedures performed by the nursing staff. So, the only indication of level of nursing care is the number of nursing reports written.

During my morning with Kelly, I learned about how patient charts are medically coded and about which services contributed most to the costs of care. How are medical supplies accounted for? How do hospitals bill for the amount of time spent on each visit? As a medical student and prior to my morning with Kelly, these concepts were foreign to me. There is little in the medical education curriculum that prepares students in a way that my visit with Kelly did.

I learned that first of all, coding and billing are two separate procedures, done by two different people, trained individually, working miles apart. The coders see only what is documented on paper while billers see only a column of numbers of which to assign monetary value. I learned that there are two parts to coding: hospital services and physician services.  The bill that results from these codes can contribute to the large bill that the patient or insurance company receives. These charges are the basis for what is negotiated with insurance companies, who use an algorithm to determine actual reimbursement rates for each patient based on risk factors. As you can see, this is a complicated business that involves many different stakeholders.

Everything documented in a physician’s note contributes to determining the level of care of the patient and in turn determines what charges get submitted to the insurance company and to the patient. It is crucial that physicians not only understand the importance of clear documentation but the effect these procedures and tests in the documentation have  on the increased costs passed on to the patient and payer.

After my experience with Kelly learning about medical coding, I am now much more aware of the information conveyed in my progress notes. The medical chart is a physician’s way of communicating the severity of the patient’s health and the amount of effort invested in the patient’s care. It is also a potential channel for documenting exams that were not performed. This process has shown me, in real time, how a plethora of unnecessary tests and imaging could increase a bill exponentially. Most importantly, there is no medical code for good or bad outcomes and there is no reward for physicians who are conscious of medical resources to cut costs of care. On the contrary, physicians are incentivized to order more tests and provide critical care measures that may be unnecessary.  I believe all medical students and residents should take a class that outlines the lessons I learned with Kelly that morning- that billing, coding, and every decision can contribute directly to the exponentially rising health costs in America.

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Jessica Jou is currently a fourth year medical student at Tufts University. She is interested in promoting medical student education on cost-awareness of healthcare. 

University of California, San Francisco

The daily “Resident Report” conference at the University of California, San Francisco (UCSF) started a little differently yesterday. The Chief Resident stood at the front of the room and asked the audience, “How many of you ordered labs for a patient this morning?”

Only 2 people in a crowd of more than 20 put up their hands.

Yesterday’s lab ordering restraint was not because of our focus at UCSF over the last two years on decreasing unnecessary services and costs of care, nor the fact that our Chair of Medicine, Dr. Talmadge King, has declared “Choosing Wisely” a Departmental priority. In fact, in 2010-2011, housestaff were offered an incentive of $400 each if they were able to reduce common labs by 5% — they didn’t.

At UCSF we have been exploring listing the prices of labs on order screens, much like was successfully done at Johns Hopkins. We have tried educational programs and feedback to reduce the costs of daily lab ordering, much like was described in the memorably titled research paper, “Surgical Vampires.”

So what finally got them to not order daily labs yesterday?

It was a strike by the patient care technical workers represented by the American Federation of State, County and Municipal Employees (AFSCME), in conjunction with a “sympathy strike” by the University Professional and Technical Employees (UPTE), which occurred at all University of California medical centers. This severely limited resources with virtually nobody in the hospital to collect and process labs.  This created a situation where labs, along with imaging and procedures, could only be performed under truly urgent circumstances.  As a result, our Chief Medical Officer reported that our medical center ordered less than half the usual number of labs.

Let’s be clear: this strike was not good for patient care and resulted in cancelled surgeries and chemotherapies, as well as the inability to accept inpatient transfers from community-based hospitals despite these patients needing specialized care. But if we are to find a silver lining of this strike, it did indeed serve as a teachable moment for forcing clinicians to think more thoughtfully about our diagnostic test patterns. Our medical service leadership counseled all teams to ask themselves “Does my patient need this test?” and “Is there another patient who needs this test more?”, simple questions that should automatically cross our minds every day in our daily work flows.  It is possible that this two-day experiment may provide an impetus to ingrain this sort of reflective – rather than reflexive – ordering practices into the culture post-strike. At least for a few days it seemed to break the stronghold of routine daily labs.

After all, our Chief Resident asked a follow-up question to the “Resident Report” group yesterday: “How many of you felt that not ordering daily labs this morning impacted your patient care or outcomes?”

Not a single hand.

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Christopher Moriates, MD (Twitter: @ChrisMoriates) is an Assistant Clinical Professor at UCSF. He is the Co-Chair of the UCSF Division of Hospital Medicine High-Value Care Committee. He works with the ACP, ABIM Foundation, and Costs of Care on educating physicians about healthcare value. 

Andrew Lai, MD MPH is an Assistant Clinical Professor at UCSF. He directs the Division’s Case Review Committee and co-directs the Hospitalist Procedures Service. He is a member of the Division of Hospital Medicine High-Value Care Committee, Quality Improvement Committee, and the Global Health Committee.   

For most of our patients, the Student Run Homeless Clinic is the last stop in a long, fruitless search for healthcare in the city of New Orleans.  Recently, an insulin-dependent diabetic came in who had his insulin pump stolen, an unfortunate side-effect of homelessness.  The physician prescribed a 150 dollar-per-month supply of insulin—far out of our price range—not knowing how much insulin costs.  This was in addition to a sixty-dollar albuterol inhaler for his COPD and lisinopril-HCTZ for hypertension.  As the pharmacy director, I was placed in the unusual position of vetoing the prescription.  How do I explain our inability to prescribe medicines to a patient who acutely needs them?  Or explain our limitations to a doctor who rarely thinks about them?  How do I justify not treating a patient to my own conscience?

I took the patient aside, and we tried to work through his options.  We explored and applied for patient assistance programs that pharmaceutical companies run for disadvantaged patients.  But for a patient who had neither a permanent address nor a phone, the paperwork proved complex.  He doubted he would hear back from them.  I referred him to the two other homeless clinics around the city, but I knew that funding for those had dried up so remarkably during the recession that they probably closed down or denied new patients.  Even if they offered his insulin, one of the clinics was not on a bus route so he had no way of getting there.  Finally, I made a referral to the public hospital.  For a non-referred patient, the hospital is so overwhelmingly crowded that an appointment can take up to three months.  Even using our accelerated referral process, the next available appointment with primary care was in a six weeks.  It was a frustrating and disheartening experience to find that every avenue was so clogged with administrative red-tape that it was unlikely he would receive help in the near future.  Much to my chagrin, we still could not write him a prescription for his insulin.  After meeting with him, it became obvious why so many homeless individuals are caught in a crippling cycle between the Emergency Department and vagrancy.

I remain optimistic because at the clinic, we make the best of our situation.  With an average annual budget of 25,000 dollars, mostly through private donations, we have over 700 patient visits in a given year.  We do this using volunteer physicians and students, an approach based empiric-therapy and a fast-track referral system into the public hospital for complex or very sick patients.  But for many, we manage chronic conditions with simple measures.  We have an in-house dispensary, for which we purchase commonly prescribed generics in bulk—antibiotics, allergy medicines, diuretics, and NSAIDs, among many others.  We also have an account at a local pharmacy, where patients can fill out reasonably price prescriptions for free.  For the vast majority of patients, we can come up with a treatment plan that accounts for the short- and long-term management of disease with frugality.

But patients such as these have forced me to think deeply about medicine in a way that seems to contradict my medical training.  We are taught that our number one priority is as our patient’s advocate.  On the other hand, as the pharmacy director, I am forced to constantly consider that one expensive patient can prevent us from treating a dozen others.  Patients thank us for our work every clinic, but for those whom we can’t accommodate, I am left wondering what else is there to do?

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Amol Sura is a 2nd year medical student at LSU Health Sciences Center- New Orleans and a contestant in the 2012 Costs Of Care Essay Contest.

]]> http://www.costsofcare.org/thechallengesoftreatinghomelesspatients/feed/ 1 http://www.costsofcare.org/connectingcostsandquality/ http://www.costsofcare.org/connectingcostsandquality/#comments Mon, 13 May 2013 08:00:02 +0000 Jordan http://www.costsofcare.org/?p=1462 By Sam Wertheimer

My research on cost measurement in health care has shown me that physicians can improve the value of care through better collaboration with financial managers.

Financial managers include business analysts, supply and equipment purchasers, operations specialists, and human resources staff. These personnel plan budgets, monitor spending, hire personnel, and report financial performance to top management and external stakeholders. Despite the vital role these staff members play in supporting clinical operations, financial managers are often disconnected from front-line clinicians.

At the same time, those front-line clinicians are often disconnected from the finances. Evidence of this can be found in a recent study showing that posting prices next to lab test options changes physician behavior. In this study cost-conscious physicians ordered significantly fewer tests.

Bridging this disconnect is critical. Physicians should be able to discuss business decisions, like purchases of the supplies they use or hiring of personnel they work with, with financial managers. During these discussions physicians can provide details regarding the clinical implications of the business decisions while the financial managers can provide further insight regarding revenue and expense implications. This communication facilitates balance between costs and outcomes and optimizes patient value.

An example of this occurred recently at one of the hospitals where I am studying health care cost management. At this hospital, physicians and financial managers teamed to discuss purchases of surgical supplies for total knee replacements. They focused on knee replacement equipment because this component of care was highly variable – both in cost and in clinical practice. The discussions proved fruitful when the group found that standardizing the set of available hardware the hospital could order larger supply batches and no longer needed different sterilization techniques for each different type of equipment. Quality was maintained despite the decreased equipment options because, with fewer choices, clinicians could more readily share advice and best practices, and this increased operating teams’ skill.

Another example of improved communication occurred at a hospital where cost-conscious plastic surgeons discussed hiring clinical support staff with human resources managers. This group compared financial models to clinical outcome predictions and found that hiring one new ancillary provider would likely improve quality, however, this change would result in increased costs per patient. However, the surgeons and financial managers also found that hiring multiple assistants could effectively streamline care processes to facilitate both lower costs per patient and improved quality.

These examples show that motivated physicians in various clinical settings are equipped to communicate and collaborate with financial managers to improve patient care and value. Becoming aware of actual care costs erases the current divide – then it’s just a matter of reaching out.

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Sam Wertheimer is a Research Associate at the Harvard Business School. There he focuses on identifying opportunities to improve health care value through accurate cost measurement.

Experts, most recently former CMS administrator Don Berwick, tell us that no less than 20% – 30% of medical care is “waste.” At the very least, “waste” is harmful to all those who pay for Medicare. But often it’s directly harmful to the patient as well.

I recently saw a friend at a party. Since we’d last seen each other my friend’s spouse had died. (I’m deliberately avoiding gendered pronouns and omitting other identifying details.) My friend contrasted the excellent hospice care the spouse received with problem-ridden hospital care. Here are two examples of “waste” that were thwarted only by my friend’s vigilance.

My friend’s spouse (“the patient”) was declining rapidly, and was admitted to the hospital. While my friend was attending to some bureaucratic aspects of the admission, the hospitalist ordered a CT and insertion of a “picc line” (“picc” = “peripherally inserted central catheter”).

On returning to the patient’s bedside my friend pointed out that an identical CT scan had been done four days earlier.

The hospitalist responded – “I don’t have it.”

My friend replied – “Rather than putting such a sick person through another CT and spending another few thousand dollars, let’s get it.”

With regard to insertion of the catheter, my friend asked: “what aspect of the plan does it serve?” The answer was – it was an automatic part of a protocol, not tailored to the wishes of the patient and family. When their goals were clarified, the picc line idea was dropped.

I know from my own practice experience that getting test results and records can be difficult. But repeating an identical test four days after it had been done elsewhere is a very expensive workaround that would have imposed avoidable distress on the patient. And although threading a catheter to place near the heart is a fairly routine hospital procedure, it carries risks (such as infection) and burdens (being hooked up to tubing). The hospital protocol should have required clarity about treatment goals before a non-emergency intervention was set into motion.

What struck me about these examples of overtreatment is how mundane they were. The hospitalist meant well. It was important for him to have the information the CT scan would provide, but repeating it wasn’t the right way to get it. And having routines can promote patient safety – but only when the routine is tailored to the true situation. In a non-emergency, getting clarity about the treatment goals of patient and family should be part of what we physicians routinely expect of ourselves.

My friend improved the spouse’s care and, at the same time, reduced costs. The public won’t be ready to consider reduced Medicare benefits or rationing until this kind of lose/lose waste is eliminated from the health system!

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The following post is by Jim Sabin, a Clinical Professor in the Departments of Population Medicine and Psychiatry at Harvard Medical School, Director of the Ethics Program at Harvard Pilgrim Health Care, and a blogger at the website “Over 65.”  Jim has been in healthcare for almost 50 years — as psychiatrist, medical director, teacher/researcher, consultant, leader of the ethics program at a not-for-profit health plan, and patient.

The pressure on physicians to provide better care at lower costs is coming from all directions – top down from policymakers who want more accountability in how healthcare resources are being used and bottom up from patients who want more transparency in how their money is being spent.  Obstetrician and gynecologists have not been spared any scrutiny. As primary care providers for many women we are in thick of the debate on appropriate use of pap and mammography screening. As surgeons we also find ourselves increasingly answering for the expense and morbidity of unacceptably high c-section rates.

While our clinical breadth provides ample fodder for scrutiny, it also may uniquely position us to help patients choose wisely among the growing panoply of diagnostic and therapeutic options. One of the most commonly encountered and difficult decisions that patients encounter is, “should I pursue medical management or surgery?” Like other specialties, ob/gyn’s are seeing surgical indications shrink as medical therapies become increasingly available and effective. Unlike other specialties, we often continue managing the patient’s condition whether she chooses surgery or not.

In a brave new world of increased healthcare scrutiny, the value of each option is only clear in comparison to the alternatives. Generally speaking, a trial of medical management is almost always preferable to surgery, even when the medicine is expensive. Take tranexemic acid (commonly marketed as Lysteda in the United States), recently approved by the FDA to treat menorrhagia: the retail price is generally more than $170 per month. However, for the correctly selected patient for whom there are limited safe medical alternatives, it is well worth trialing over the potential pain, inconvenience and several thousand-dollar price tag of surgery. Leuprolide acetate (Lupron), most often used for endometriosis-related pelvic pain, is another example of a very expensive medication (close to $1000 for a three month dose) that could be a good value for the correctly selected patient who does not want to commit to an operation.

Opportunities to help our patients get a good value extend beyond those who wish to avoid surgery. The most common group of medications prescribed by ob/gyn’s are oral contraceptive pills (OCPs), given for a variety of non-contraceptive indications ranging from endometriosis to irregular menstrual cycles. Although there are hundreds of readily available OCP formulations, most of us generally prescribe a small subset that we are most familiar with and consider a limited set of clinical factors. It appears that making cost one of those factors would be particularly worthwhile. Prices of OCPs vary by an order of magnitude. Many available generic options cost less than $10 per month while the newest brand formulations can cost closer to $100.

Despite routine opportunities to help patients make high value decisions, this is often easier done in theory than practice. Patients may present for care with fixed expectations and taking the time to counsel them about the full range of available options is already challenging. Adding cost information to this task creates an extra dimension of complexity. Moreover, cost and value are not always easily ascertained and will typically vary according the patient’s clinical circumstances, personal preferences, and particular insurance plan.

Fortunately, there is a growing body of resources available to help. Medication costs can now be queried online by pharmacy at sites like GoodRx.com. Professional societies, including the American Congress of Obstetrics & Gynecology, are developing lists of high yield opportunities to improve value. Organizations such as the American College of Physicians and Costs of Care provide online training opportunities in cost-conscious care. Choosing wisely and delivering value in obstetrics and gynecology is not always easy or straightforward but I truly believe that we are up to the task.

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Neel Shah, MD, is a chief resident in obstetrics and gynecology at Massachusetts General Hospital and Brigham & Women’s Hospital in Boston, MA. He is also the founder and executive director of Costs of Care, a grant-funded 501c3 venture. He can be reached at neel@costsofcare.org. 

“Have you ever been told you have a heart murmur?” a young doctor gently asked my friend, Ben. Ben’s mind reeled. Ben was in his early 30s, relatively young and healthy.  But his father had died from a heart attack before age 50. And his mother had a heart problem.  What did this question signal for him, he worried.

“Um, ah, no, I haven’t,” Ben managed to murmur in reply.  The doctor told Ben he wanted to get a sonogram to have a picture of Ben’s heart. He scribbled an order on a form and told Ben of a nearby cardiologist. Ben thanked the doctor and wrapped up his appointment. As soon as he left, Ben called me. We have been friends since grade school, and we shared everything. When I heard his voice I could tell he was upset.

It was his first visit to the new doctor, a young physician at a trendy new concierge practice. He said he worried the doctor was jumping to conclusions in his recommendations. Puzzled, I reminded Ben that the test was merely a preventative measure. But, I suggested, with his family history, he would be wise to get his heart checked out.  An ounce of prevention is worth a pound of cure, I teased. Then the real truth came out: Ben was worried about the cost of the test. Ben explained he called the cardiologist before he called me. He was shocked to learn a sonogram was $1,200 if he paid out of pocket.

“Twelve hundred bucks?” Ben complained over the phone. “That’s outrageously expensive for a simple test,” he whined. I found myself  momentarily distracted by wondering about the costs of technology, malpractice insurance costs, physician practice trends, but I bit my lip. “I agree,” I simply said. And I did agree. I could rationalize a few elements in a cost analysis, but like Ben, I felt $1,200 was too just too much for the simple test.

Then the obvious question hit me. “Wait, why pay in cash, Ben?” I asked. “Why not have your insurance pick it up?” Ben had a good job with great insurance. Surely the insurer would cover at least part of the tab.

“I’ve not met my deductible yet this year,” he explained in a dreary voice. “I already called them and would be on the hook for about four hundred, even with insurance.”

That was a mere third of what Ben had been quoted if he paid out-of-pocket, so I didn’t see why he was still reluctant to have the sonogram. Ben explained that his budget was tight and even $400 was a lot for him. When Ben and his wife had a baby several months prior, I had wondered at the time how expensive the couple of weeks in the NICU had been.  Now the pieces came together.

I sighed. I knew where Ben was coming from. Years ago I had avoided the dentist for far too long. Though I saved on a dental plan in the short term, my neglect led to pricey repair work down the road.  It’s natural to want to skimp on care when it’s costly.

Recollecting my thoughts, I explained that while preventative tests may not be cost-effective for large swaths of a population, with his family history and doctor’s recommendation, I thought he should have the test.

***

Several days later I received a phone call from Ben. He had been to the cardiologist and did not have a heart murmur, he explained happily.  But he did learn something very important.

The sonogram showed that part of his heart wall was enlarged.  His doctor surmised that hypertension –elevated blood pressure – was the likely culprit. Since hypertension increases the risk of heart problems, with Ben’s family history, the doctor put Ben on a low dose of blood pressure medicine.  The cheap generic prescription cost Ben only $4 a month at the pharmacy.

I asked Ben how he felt about the outcome.

“Honestly,” he said, “I am relieved to know what’s going on with my health.” He sighed.

“That four hundred dollars was a lot, but it may have saved or lengthened my life,” he said in a serious tone. “And, for the price of just four dollars each month,” he said more lightly, “now I’ll be around for even longer.”

I thought of my friend and his new baby. And I smiled.

“Yes, you will, Ben,” I said. “Yes, you will.”

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Josh Trent from Maryland was a contestant in the 2012 Costs of Care Essay Contest.

I had been laid off a few months when my ulcerative colitis kicked in, and my doctor and I struggled to get it under control.  After trying a variety of medicines, my health continued to deteriorate and I agreed to take Remicade.  Remicade is a potent drug, administered through an IV infusion at the oncology center that comes with a whole host of potential side effects.  The dosage requires an initial cycle of 4 infusions spaced several weeks apart, then a maintenance dosage every 8 weeks thereafter.  The decision was not taken lightly.

I was very worried about both the side effects and the cost of the drug, although I was so sick at the time, that I was more worried about whether the drug would bring me quick relief.  I did make a feeble attempt to find out if Remicade was covered under my husband’s and my insurance plan.  After several phone calls where I was transferred around, and several hours of searching through the Blue Cross documentation on line and in its services catalog, I gave up.  My logic was that if I couldn’t find anything explicitly stating Remicade was not covered, then it must be a standard service requiring just another copay. I had never had to pay anything more than a copayment for my medical care so far, and I was hopeful that the charges would again be minimal.

I then spent days searching the internet to learn more about the medicine, potential reactions I could experience, and for patient forums to better understand what I might be facing.  Many of the people mentioned the high cost of the drug.  Even though I tried to ignore these comments, deep down I was very nervous that we would end up with a large medical bill just when we were reassessing our finances.

I had already had my first three infusions before I got my first explanation of benefits – and by then I was well on the road to recovery and I was not about to give up my “wonder drug.”  I was caught completely off guard, however, when I saw that the cost of the medicine alone was $12,000. The insurance company negotiated the cost down by almost half, and when all was said and done, my out-of-pocket was nearly $1,500.  Already, I was fast approaching $5,000 in medical expenses, and I still had several more treatments scheduled for the rest of the year.

My husband and I pored through our insurance paperwork and discovered that our yearly out-of-pocket caps at $5,000, after which time all other costs are covered by Blue Cross for the remainder of the year.  I started to feel better knowing that we would not have to pay more than $5,000.  But I was still distressed to know that this medicine was so expensive.

I immediately contacted the hospital and requested an itemized bill to ensure that all charges were correct.  The items charged seemed valid to me so there wasn’t anything I could dispute.

I vaguely remembered reading something in one of the patient forums about a financial assistance program that would help with the cost of the medicine.  I went back to surfing the internet and I found the pharmaceutical company’s Remistart program through which a portion of a patient’s out-of-pocket expenses could be reimbursed.

I was accepted into the program, and I was ecstatic to learn that I would get a rebate for nearly half of my total out-of-pocket charges.  That was nearly four years ago, and today I am still receiving Remicade treatments, and I am still covered through the Remistart program.

Two years ago my dosage for the medicine was doubled and, not surprisingly, the cost of the medicine doubled as well to nearly $25,000 per treatment.   I asked the Remistart representative if they had an idea of the cost of treatment at the different hospitals. The person reported that the costs are negotiated between the hospitals and the insurance companies, and the company did not have that information.

I have since learned that financial assistance is available through other companies as well.  This information is something that physicians should let their patients know about.  The programs can mean the difference between receiving the drug and not.

I am grateful for this program, but I still worry about the high cost of the medicine. And each year I cross my fingers that the Remistart program continues, and again accepts me into the program.

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Nancy Meredith is a patient in Wake Forest, NC and was a contestant in the 2012 Costs of Care Essay Contest.