My $4.07 check from an insurer: A sign of the times

At a recent party, I had a conversation with an attorney friend about the income professionals like us receive. This lawyer volunteers as a public defender in her hometown and spent most of the party detailing the terrible financial shape that most public defender offices are in. Having seen a few cop shows in my life, I challenged her on this. I reminded her that unlike medicine, the right to an attorney is guaranteed by the Constitution (the Sixth Amendment for those who are curious).

To support her claim, she quoted an article from The Atlantic that public defenders in New Orleans are paid $9 a case on average. She did admit, though, that the average case takes less than 10 minutes. But she was aghast at the situation, nonetheless.

I laughed. It probably wasn’t the politest thing I’ve ever done, but having had a few beers already, it seemed appropriate at the time.

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I then proceeded to tell her a story of my own. (As always, some details have been changed to satisfy the HIPAA lawyers.) It was about 2 a.m. one recent call night when my pager went off. One of the better ER doctors told me about a 50-something, morbidly obese, diabetic female with a significant heart history who presented with a week-long history of left flank pain. Earlier in the evening, her pain had worsened and she developed a low-grade fever, which brought her in to the ER.

CT showed an 8-mm proximal left ureteral stone with hydronephrosis. Her white blood cell count was 16, temperature 100.5, and urine grossly infected. Vitals were otherwise stable. The ER doctor had already contacted medicine to admit her. On exam, she had mild costovertebral angle tenderness and her pain was not well controlled despite ketorolac (Toradol) and IV narcotics. She clearly had an infected obstructing stone but wasn’t septic yet.

By 3:30 a.m., I was in the OR where I placed a stent without difficulty. I rounded on her for the next few days while she was treated with antibiotics before being discharged.

I billed a 99204 (new patient visit) with a 57 modifier (decision for surgery) and billed the case as a 52332 (cystoscopy and stent placement). I suppose I could have billed the patient for each day I rounded on her, but I didn’t.

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Her insurance was the Colorado Indigent Care Program, CICP. CICP is a program run by the state of Colorado that is designed to provide health insurance for low-income legal residents of Colorado who are not eligible for Medicaid (annual income limit of $59,625 for a family of four). I always ensure I get a copy of the patient demographic sheet for my billers when I see a new patient in the ER, but I rarely look at it as it really doesn’t matter; she needed surgery and I was on call. 

Next: "The check was for $4.07. Total. Sum. Finale."

A few months later, our office received a check from CICP for my services. My group had billed a total of $1,332.25 for my services (both the consult and the procedure). The check was for $4.07. Total. Sum. Finale.

When my office manager first showed me the check, my first reaction was that I had made a mistake in my billing. But our billers confirmed I did everything correctly. My second thought was that this was a partial payment; again, we checked with our billers and that wasn’t the case. 

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I live about 15 miles from the hospital, so given the drive to and from the hospital, the check probably covered the cost of gas. Probably. Ignoring my commute, I probably spent about 2 hours seeing the patient in the ER, doing the case, and writing notes and such, which means I was paid $2.04/hour-somewhat less than what a McDonald’s worker in Seattle gets nowadays. And while I don’t know what they pay on a yearly basis for malpractice insurance, I’m pretty sure my cost is higher than theirs.

I asked my lawyer friend if I should go on and suddenly the topic turned to soccer, something that we both enjoy and is less controversial.

Anyone who reads this blog knows I believe in a health care system where private practice physicians have a strong role. I feel that large state institutions, whether the VA or a state university, can’t hope to compete with the efficiency of a private practice physician. But certainly not everyone agrees.

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A year ago, with the delivery of my twins, I learned a very valuable lesson on how consumers of health care view the health care delivery system. I gained first-hand experience with how hyper-capitalism run amok can devastate a family, even when that family had desperately tried to play by the rules. But I also understand that there are two sides to any argument and while I am likely preaching to the choir with this blog, an advocate for a single-payer system may just happen to read this and learn how those of us on the other side view such a system.

A single-payer health care system (such as CICP or, for that matter, any system that requires providers to provide services without the ability to negotiate cost) is nothing more than nationalization of health care providers’ time, effort, and skills. Over the last few years, I have employed multiple professionals for various reasons-accountants for my taxes and lawyers for help with my health care bills, to name a couple. To my knowledge, none of these professionals are required to provide services to whomever walks into their office for $2.04/hour even if that person desperately needs their services.

Next: Another insight into single-payer systems

A second recent stone case offers more insight into another drawback of a single-payer system. I received a page from the ER at about midnight regarding a healthy 30-something who had walked into the ER earlier in the night reporting terrible sudden-onset flank pain. CT showed a 2-mm distal stone with mild to moderate hydronephrosis. Urine was clean, white blood cell count normal, and no fever, but his pain could barely be controlled in the ER with large doses of IV narcotic and ketorolac. I called in the OR team (the hospital in this case does not keep an OR team in house) and removed the stone ureteroscopically.

Two weeks later, when I saw the patient back in my clinic to discuss stone analysis and stone prevention, he said I did a great job. I thanked him and asked him if he had any comparison. He said he was new to town (he had no insurance), but he had a history of multiple stones requiring intervention (something he specifically did not mention the night of surgery). I asked why he hadn’t told me that earlier and he said that other urologists had refused to operate on him when he had small stones.

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Given the recurrent nature of the disease, I then recommended a 24-hour urine collection and a metabolic evaluation. But he declined, stating that it was easier for him to wait until he had a recurrence and then go to the ER.

In a single-payer system where health care is free, demand becomes unlimited. Why bother with taking potassium citrate that upsets your stomach or drinking sufficient fluid if free high-quality health care is always available? But the situation is worse than that. In a single-payer system where I as a provider am placed on a salary, why should I operate at all?

Think again about that second case. The odds of passing a 2-mm distal stone spontaneously are very high and the patient in question wasn’t infected. So maybe if he had been admitted and hydrated, we might have avoided surgery entirely. In that setting, perhaps the in-house medicine team could have done the admission and maybe I could have slept that night and not had to call in the entire OR team.

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It may seem like a crass concept, but I guarantee that it happens-especially as we see treatment algorithms like those used frequently at some of the state-sponsored health care systems that operate near my office.

I don’t claim to have an answer to the challenge of providing health care to every citizen of this country. I just know that this small-town plumber is becoming frustrated at providing care to patients enrolled in certain government-sponsored health care programs whose reimbursement is nowhere near covering my costs, let alone paying my mortgage.

If anyone else has experience with this situation or has an idea about how to best make our voices heard, please write me at UT@advanstar.com or sign in below to post a comment.

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