Rising healthcare costs are busting the federal budget, to say nothing of family budgets for anyone who’s privately insured, as we are. Policymakers and healthcare leaders have spent decades trying to figure out what to do about this mess—to no avail. No one knows what it really costs to deliver care to individual patients, much less how those costs compare to the outcomes achieved.
Because healthcare charges and reimbursements are disconnected from what they actually cost, some procedures are reimbursed very generously, while others are priced below their actual cost or not reimbursed at all. This leads many providers to expand into well-reimbursed procedures, like knee and hip replacements or high-end imaging, like PET and MRI. At the same time, critical services like primary and preventive care are reimbursed poorly.
My point: A lot of expensive medical care could be avoided and vast sums of money saved if gatekeeper physicians and nurses, and the simple procedures they order, were better reimbursed.
Regardless of whether they’re necessary to make their patients well, hospitals and doctors are paid handsomely to perform lots of sophisticated procedures and tests. Providers who excel and achieve better outcomes with fewer visits, procedures and complications are penalized by being paid less. If you doubt me about this, ask your pediatrician or family practice doc what they think.
As patients, it’s rarely in our financial interests to question the system. If you have a job and have employer-funded insurance, you’re still largely insulated from the absurdities of a system that encourages consumption of often needless healthcare. Because I’m not, I occasionally spar with the powers that be—mostly for my own amusement. On rare occasions, I win.
My most recent interaction could be called a draw. At a surgery a few weeks ago, I had three subcutaneous mets surgically removed by my oncologist. Like previous surgeries, the procedures were fairly simple and uneventful. As is my habit, I asked to see the tumors after they’d been dropped into small containers of formalin and before being sent to the path lab for analysis. I thought on this occasion to ask my surgeon, “We’ve been through this drill before. Since we both know they’re cancer, what’s the point of sending them to the lab?”
I don’t recall exactly how Dr. V responded, but he overruled my objection. I didn’t protest. The cost of the lab work quite honesty wasn’t on my mind. It’s just that I’ve developed an amateur, but fairly refined sense for what metastatic melanoma looks like. I figured there wasn’t much the pathologist could tell us that would remotely affect my present or future oncologic care.
A few days later, my surgeon called to report the obvious: all three samples were positive for melanoma. No surprise there.
I received a statement from OHSU last week that breathed new life into this story. The $900 I was billed for pathology (technical component only) was disturbing enough, but what bothered me most was this charge being about three times more (per met) than my two previous, nearly identical surgeries. I checked the CPT codes on my insurance statements for those dates and found that they were at variance with my current bill. I called my insurance company (Regence BlueCross BlueShield) and the claims representative with whom I spoke seemed unperturbed by this observation. She assumed there was some added complexity to the most recent path samples, and declared everything good. OHSU’s charges were indeed correct based on the code provided.
I then emailed my surgeon, who to his credit is good about reading and responding to the occasional message I send him (unreimbursed care, I figure). I asked him specifically about the CPT codes and why they were divergent. His answer: All tissue samples suspected of being malignant are sent for path because OHSU is an NCI cancer center and thus obligated to test them all. He added that not everything that looks like a met is a met, and that he couldn’t remember ever not sending something that could be malignant to path.
I have no interest in challenging Dr. V's clinical judgment, but I remain in the dark about the CPT codes. I don’t understand code nomenclature and I know there’s arcane science behind what codes are assigned to specific procedures. It’s also possible that this was a matter of something simply being coded incorrectly. Mistakes happen, though not often admitted to, by people who are justifiably afraid of being sued. I don’t intend to press my doc on this matter but I'd love see a little more candor.
What bothers me the most about this matter is that nothing changes, nor had any chance of being changed, by some lab technician presumably conducting an added level of investigation of my samples. She or he simply sliced and diced them differently. Given that they were conspicuously malignant, there really wasn’t any worse news I could have learned. Even if the “mets” had miraculously all come back negative for melanoma, nothing in my life would change. I’d still be stage IV, I’d be watching for the appearance of new mets under my skin, and I’d be checking in again with my surgeon if and when something shows up. This is simply one small drop of medical overkill in a veritable sea of excess. Everyone involved in my follow-up to the $900 bill has given it a collective shrug. If I’m not hurt by it—other than financially—why should it matter?
In fairness, I should mention that the charge may eventually be reduced. Dr. V copied his nonresponse response to the chair of surgical pathology at OHSU, who cc’d it to her department’s billing and coding expert. It’s possible that my charge may yet be adjusted. I would appreciate that, but would equally like to know what actually happened here. Why were the samples coded differently after very similar surgeries? Is the system really that loosey-goosey? Does anyone ever get audited about this stuff? What is the NCI’s reason for requiring that everything cut out of cancer patients go to path?
I’m bothered a lot by the excessive cost of healthcare and by cavalier attitudes towards the system’s profligacy. I wage these quixotic raids not (just) because I’m a crank but because I figure if more of us did so, it might make a difference. I don’t wish the kind of insurance we have on anyone, other than perhaps the totally uninsured, who might actually appreciate it. It’s because my wife and I have considerable financial exposure that taking the time and effort to ask questions about our care makes sense. I’m looking less for charity than for answers, and ultimately for the sort of accountability that is grossly lacking in much of the healthcare we all receive.