About that $39.35 charge for holding a newborn baby

By now you've probably heard about the hospital that charged $39.35 for a woman who just had a cesarean section to hold her baby.

The baby's father posted a copy of the bill on Reddit, and it drew over 11,800 comments. The story was also widely circulated on Twitter.

At least one labor and delivery nurse on Reddit and a spokesperson for Utah Valley Hospital where the baby was born stated that the charge was not for holding the baby, but rather it was because an extra nurse had to be brought into the room to watch the baby while the first nurse took care of the mother.

I'm not buying it. The only way to justify charging for the presence of a second nurse would be if she had to be called in from home. If the nurse was already in the hospital which I'm sure she was, the five or so minutes that it would take for her to stand by while the mother holds the baby would surely not take her away from the routine duties of a labor and delivery nurse.

This is especially true for Utah Valley Hospital which delivers about 3600 babies per year. Only about 30% of them or about three per day are born by cesarean section.

And who says a second nurse is even required? Most cesarean sections are performed under epidural or spinal anesthesia. The mothers are awake and perfectly capable of holding a newborn child. An anesthesiologist or nurse anesthetist is always in the room and is primarily responsible for caring for the mother anyway.

Like most hospital charges, the $39.35 figure appears to be the product of some bean counter's imagination. Why $39.35? Why not $39.95 or $68.87?

Apparently Intermountain Healthcare (a system which includes Utah Valley Hospital) has some other interesting billing practices. This is what one Reddit commenter had to say:

Hey, I know this world: we had to pay $700 for our son to stay in my wife's room. Here, I'll explain: my wife was billed $700 per night after her c-section, and my son was also billed $700 per night for his room.

Here's the kicker: they shared the same room!! So, I thought it was a mistake, right? So I called the horrible people at Intermountain Healthcare to point out that they had billed two charges for the same room. They're [sic] response? "We bill each patient for the full room charge." Yep, they billed my wife $700 for her room, and my baby $700 for the same room. They also doubled the nurse charges (even though, again, my baby didn't have his own nurses.)

He refused to pay, and the bill was sent to a collection agency.

Congratulations on the birth of your son.

Health Care and the $20,000 Bruise: A different take

Twitter is buzzing about yet another medical billing horror story. This one appeared in the Wall Street Journal and was written by Eric Michael David who is an MD PhD JD and an officer at a biotech company.

He saw a large, swollen bruise on his three-year-old son's head several days after falling off his scooter. Other than the bruise, no other abnormalities were mentioned. He took the boy to "one of the top pediatric emergency rooms in the country" to have a CT scan done. It showed "a small, 11-day-old bleed inside his head, which was healing, and insignificant."

Dr. David received a bill for $20,000, $17,000 of which had been paid by his insurance company. He was responsible for the remaining $3000.

He noted a $10,000 charge for a trauma team activation which he said never happened. After a lengthy series of exchanges with the hospital's billing department and Dr. David having to prove that a trauma team activation was unwarranted and not permitted by certain regulations, he was able to have the charge rescinded.

The essay went on for some 1200 words listing the steps that he went through. He correctly described what a mess American healthcare delivery is and why as long as overuse and upcoding are rewarded, the Affordable Care Act will not fix it.

Dr. David was right to contest the $10,000 charge for a trauma team activation that wasn't indicated and didn't even occur.

What he didn't address was this.

Why would a doctor who said that he had "served on trauma teams in two of the busiest hospitals in New York City" feel the need to take his apparently asymptomatic son with an 11-day-old injury to an emergency room for a CT scan?

Doesn't this imply overuse of a different type?

Secondary questions:

Did anyone bring up the issue of radiation from the CT scan?
Did the docs in the ED think a CT scan was necessary?
"Inside his head" is a rather odd phrase. Does it mean intracranial? Intracerebral?
Was "one of the top pediatric emergency rooms in the country" the only option or could this asymptomatic boy have been seen in a doctor's office?
Why is the charge for a trauma team activation $10,000?

A different take on Medicare's release of doctor payment data

Journalists have had a good time with the Medicare data on payments to doctors. The most recent exposé is headlined "Taxpayers face big Medicare tab for unusual doctor billings" by the Wall Street Journal. Because of a paywall, most people did not have a chance to read the article.

It recounted several anecdotes about physicians who received huge amounts of money for procedures of dubious worth. I will summarize two of them.

In 2012, an internist in Los Angeles was paid close to $2.3 million for a procedure known as "enhanced external counterpulsation," or EECP, which is supposed to ameliorate angina in patients who are not surgical candidates.

Although not a cardiologist, he apparently used EECP on 615 patients. At the Cleveland Clinic, whose chairman of cardiology says the procedure should rarely be used, the procedure was performed on only 6 patients in a year—that's 6 patients total by a staff of 141 cardiologists.

A Florida dermatologist received $2.41 million from Medicare in 2012 for 15,610 radiation treatments for melanoma in 94 patients, an average of 166 treatments per patient. The usual number is 20 to 35 treatments. The doctor said he billed for each lesion separately and treated each one about 40 times.

A radiation oncologist who was interviewed questioned the appropriateness of the machine the dermatologist was using and said, "When a patient has several lesions, they commonly get treated simultaneously and are billed for as a single treatment, he said."

That is the way Medicare handles most multiple procedures. At best you might get away with billing a partial amount for an additional treatment.

Any physician who has spent time in the private practice of any medical specialty that involves the treatment of elderly patients can tell you that Medicare will nickel and dime you to death over a minor dispute about an evaluation and management code.

Medicare is also notorious for holding back money due to physicians who are just trying to make a living. A classic ploy is to request a copy of the dictated operative note for a simple procedure. This will add 4 to 6 weeks to the eventual cutting of a check.

They routinely perform unannounced on-site audits of doctors offices looking for discrepancies in documentation. I once experienced one myself and luckily was not cited or fined.

Here are some questions that I haven't seen any journalist ask.

Why does the Wall Street Journal have to point out such flagrant outliers? What does the Wall Street Journal know about detecting these practices that Medicare could not do for itself? How can Medicare continue to pay top dollar for questionable treatments and billing practices? Why doesn't Medicare do something simple like automatically reviewing any practice that receives more than say $500,000 in a single year?

Inquiring minds want to know.

What's your opinion?

Just how screwed up is the US medical system?

Let me count the ways.

Here are three recent stories that highlight what's wrong with our medical system.

An in-depth report by the Tampa Bay Times found that hospitals in Florida are charging exorbitant fees for patients arriving at trauma centers. It led with an account of a patient who spent 40 minutes in a Fort Pierce trauma center before being transferred to another institution for a higher level of care. After some diagnostic tests were done, he was on his way. The tab for the 40 minutes? $32,727.

The Times found that the average charge for a trauma center activation was over $10,000 and the highest was $33,000. For-profit hospitals tended to charge the most. These charges were billed regardless of nature of the injuries, be they minor cuts or abrasions. And as is customary today, the uninsured were charged the full amounts.

Hospital administrators admitted that the charges were based on what other hospitals charged and had no relationship to what resources were used. The fees did not include bills for physician services, which were separate.

Do more hospital resources equal better care?

For surgical patients, the answer is "Yes."

A recent study from England found that mortality rates for patients admitted with high-risk general surgery diagnoses were significantly lower in National Health Service Trust hospitals that used more CT scans and ultrasounds and had more ICU beds.

During the first decade of this century, nearly 368,000 patients were admitted as emergencies to English hospitals with surgical diagnoses carrying mortality rates in excess of 5%.

The diseases were bowel obstruction, liver/biliary conditions, hernias with obstruction or gangrene, peritonitis, gastrointestinal ulcers, perforated diverticulitis, bowel ischemia and miscellaneous diagnoses.

The 30-day risk-adjusted in-hospital mortality rate for the eight illnesses was 15.5% with a range of 9.2% in low-mortality hospital trusts (LMHTs) to 18.2% in high mortality hospital trusts (HMHTs). An operation was performed in 37.4% of patients, and 14.9% were readmitted within 28 days.

Three factors significantly differentiated LMHTs from HMHTs:

LMHTs had 20 ICU beds per 1000 beds vs. 14 for HMHTs, p = 0.017.

LMHTs performed 24.6 CT scans per bed per year vs. 17.2 for HMHTs, p < 0.001.

LMHTs performed 42.5 ultrasounds per bed per year vs. 30 for HMHTs, p < 0.001.

Some limitations of the study included the fact that it was based on administrative data. There was no way to determine if the increased use of imaging or availability of ICU beds had a direct effect on patients admitted with emergency surgical diagnoses. Also, variables such as delays in surgery or competence of surgeons could not be investigated.

Despite its limitations, this study is provocative.

No doubt the HMHT hospitals, which have fewer ICU beds and perform fewer imaging studies, are not as expensive.

But the study suggests that if you have the misfortune to arrive at an HMHT hospital with one of the surgical diagnoses listed above, you may have twice the chance of dying than if you had gone to an LMHT hospital that utilizes more resources.

This study is supported by a Viewpoint article in October's JAMA Surgery which looked at two studies of postoperative care in the UK and Europe. In both papers, many seriously ill postoperative patients did not receive appropriate levels of critical care. "Among patients who died during hospitalization after major surgical procedures in the United Kingdom in 2001, approximately 8.5% were admitted to an ICU at some point in their hospital stay. During the same period in the United States, this figure was 7 times greater, 61%."

In the European study, only 5% of surgery patients had planned admissions to intensive care, and 75% of those who died postop did not spend any time in an ICU.

The authors added, "in efforts to achieve good surgical outcomes, there really may be no free lunch: tradeoffs between cost and quality are inherent to the contemporary delivery of intraoperative and postoperative care."

What do you think?

Lawyer tricks of the trade: Billable hours

Lawyers are hardworking people. That's for sure. Take this lawyer from Ohio who billed long hours for court-appointed cases. For instance, he billed for 21, 21.5, 23 and 29 hours of work for 4 different days. His lawyer said he did the work but was simply a poor record-keeper.

Right.

Not to be outdone, a lawyer from Iowa billed for more than 24 hours of work in a day on 80 separate days. He is being charged with a felony for receiving $178,000 for what are being called improper payments for work as a public defender.

Four other lawyers were terminated from the program for similar issues.

And you thought doctors worked long hours?

The president of the Iowa State Bar Association called the findings of the audit that discovered the problems "an isolated aberration, involving five lawyers. Simply put, a few bad apples do not spoil the barrel."

Are these isolated aberrations?

I'm not so sure. A lawyer friend of mine (yes, I do have friends and even relatives who are lawyers) tells me that this is not particularly uncommon.

He said that lawyers will often schedule 5 or 6 case conferences at a courthouse over a 2-hour period and bill each client for 2 hours worth of work.

At least one lawyer feels that the "billable hour" model should be scrapped because "The billable hour makes no sense, not even for lawyers. If you are successful and win a case early on, you put yourself out of work. If you get bogged down in a land war in Asia, you make more money. That is frankly nuts."

This meshes nicely with a story my lawyer friend told me. Shortly after he became a lawyer, he proudly walked into his boss's office to report that he had settled a case in record time. His boss then chastised him for doing so and pointed out that settling the case so quickly cost the firm a lot of money.

It's too bad that legal services are a "privilege"instead of a  "right." Then maybe someone other than I would be upset about how much it costs.

Wide disparity found in hospital charges for appendicitis. Why?

If you wonder why hospitals are under fire for outrageous and often baffling accounting practices, look no further than a brief paper published last month in Archives of Internal Medicine.

 

Hospital charges for straightforward appendectomies done for acute appendicitis in California in 2009 were examined with the following inclusion criteria:

• Patients between the ages of 18 and 59
• Hospital stays fewer than 4 days
• Discharged home

For the more than 19,000 records reviewed, the median hospital charge was $33,611 with a low of $1,529 and a high of $182,955. Not included in the article but mentioned in news stories about the paper were more details about the care of the two patients at the extremes of charges.

From the Huffington Post: “The costliest bill, totaling $182,955, involved a woman who also had cancer. She was treated at a hospital in California's Silicon Valley. Her bill didn't show any cancer-related treatment. The smallest bill, $1,529, involved a patient who had her appendix removed in rural Northern California. Otherwise, the cases were similar: Both patients were hospitalized for one day, had minimally invasive surgery, and had similar numbers of procedures and tests on their bills.”

A California Healthline story about this clarifies the issue. It said,“Dave Glyer, CFO for Community Memorial Health System, said that the study ‘assumed that hospital charges matter when they don't,’ making it ‘completely off base.’ He said that insured patients pay rates negotiated by health insurers and that certain uninsured patients are aided by assistance programs.”

It’s all clear to me now. Hospital charges don’t matter.

What if you have no insurance and are not one of the “certain uninsured patients” who are aided by assistance programs? You are on the hook for the entire bill unless you can negotiate too.

What’s not clear is how the median hospital charge for a simple procedure such as an appendectomy can be $36,611 with such a large variation. 

May we see an itemized bill for the $182,955 please?

Radioactive man? Milford resident pulled over by state police

A few days ago, a 42-year-old man was stopped by a state policeman because radiation coming from his vehicle was detected by a device in the patrol car. Earlier that day, he had undergone a cardiac stress test which involved the injection of a small amount of radioactive isotope into his body. He was released when he produced a doctor’s note stating he had undergone the test. [Full story here.]

Two things make this story interesting.

One, the report reveals the fact that many police cars have radiation detectors that are so sensitive that a man emitting a small amount of radiation while driving could be fingered as a possible terrorist. Despite my being a news junkie, I did not know that such detectors were deployed. Did you?

Now the terrorists know too. What is to stop them from bringing a nuclear weapon into a city now that they are aware of the existence of these detectors and that a note from a doctor can get one off the hook?

The second interesting point involves the stress test. The story says the man had what seems to have been a transient hypertension. There was no mention of any cardiac symptoms or a family history of heart disease. The man is employed as a fireman, a strenuous occupation.

Why was a nuclear stress test ordered?

I am a mere, “non-cognitive” surgeon, but I believe that an asymptomatic 42-year-old fireman with hypertension, episodic or not, does not need a cardiac stress test.

Do you wonder why we spend so much on health care in the United States?