19. Self-financed medical care -- A case study

This posting is in the context of the ongoing furore about the overhaul of medical care in the US.  Much of what we have been hearing about have no faces attached to them, and so in some sense remain abstract. This blog entry -- which is an actual letter written to hospital authorities -- presents a real-life case study, elaborating on  the kinds of charges patients are highly likely to see in their hospital bills -- charges that they usually do not care about or take the time to decipher since they don't directly pay the bills. But, with more people expected to become uninsured, it is imperative that we get familiar with them.

The purpose behind the sharing of our case is to educate and inform.  The actual players in this case are not important, but the scenarios and their implications are. I hope others  will come forward and share their experiences, nay, nightmares.

Comments, as always, are welcome.

--------------------

Dear Doctors:

Greetings !

At the outset allow me to introduce myself. I am Prof. Krithi Ramamritham, Former Dean of Research and Development, Indian Institute of Technology, Mumbai, India. I have lived in the US for over 20 years (during which time I was a tenured professor at UMASS). I am a US citizen and both my children are studying in the US. I am considered to be an accomplished computer scientist and returned to India to enhance its research potential in information technology and computer science, but I continue to travel back and forth.

In December 2009, I was diagnosed with Leukaemia in India. We had several options, but ... undoubtedly your hospital  was our first choice and we are glad to have made that choice. My medical record number is ... . At that time however, I had no medical insurance in the US but had to leave for medical care immediately, as the window of opportunity for treatment was small.

We were asked to pay a deposit of $40,250 which we did before we arrived here. Subsequent to seeing me in person and based on results of diagnostic tests, decision was made by Dr. ...  to proceed with a Bone Marrow transplant, at which point we were asked to pay another deposit based on a detailed estimate. So we paid up a total of $276,950 upfront. However, to our dismay my family discovered that even before the transplant, the balance in my account was just $12,000! And, this is on the 7th day after admission and without any complications. Of course this imposed a great amount of stress and anxiety for my family, as we had borrowed heavily to comply with the prepayment requirements of your hospital.  My family, out of concern for my health, shielded me from this news. If I had known then I would most certainly have reconsidered our previous decisions.

I have now seen all the letters and the discussions my family members had with you. I was very happy to know from my wife and brother in law, the consideration you have given to our case. I was also briefed by my brother in law that Dr ...  specially met him and assured him that he and Dr ... would do the needful and find a fair solution and help the family. He also reassured that the family should not worry about the financial aspects and should look after me very well and Dr ... and Dr .. will try and do their best on the financial aspects. Thereafter, I understand that my family members met Ms. .... While she conveyed that Mr ... has approved a special discount of 15% on the gross billings from the first dollar, we explained to her as to why we deserve a much higher discount than the 15 % specially approved by Mr ... We also followed up with a mail giving all the justification. I would like to present the justification once again here:

o       I am a US Citizen but unfortunately uninsured when I was admitted.

o       I file my tax returns in the US and has been paying taxes. My adjusted total income was about $xyz for the year 2008 and about $xyz for the year 2009.

o       Since the doctors that we consulted suggested that it is best for me to go ahead with the bone marrow transplant immediately without losing time we decided to go ahead with this decision even though the insurance through my visiting position at UMASS commenced from 1st July, 2010 and only the expenditure incurred after this date would get covered under such insurance.

o       We were asked to pay a deposit of $ 276,950 which we paid promptly in a matter of few days time. In order to meet this, we had to borrow and fund the treatment. You have to appreciate that it is extremely difficult for an ordinary person to promptly respond to a huge payment obligation of $ 276,950.

o       The deposit of $ 276,950 included about $ 150,000 for transplant which would cover hospitalisation for about 40 days (10 days prior to transplant and 30 days post transplant), all the labs, diagnostic investigations, doctors' visits, medicines and IV infusions, etc. It also included about $ 63,000 for 90 days visit to the hospital post discharge. My performance so far has been above average (as confirmed by the doctors) and I stayed in the hospital only for 23 days (instead of 40 days as estimated) and luckily I have had no complications and since I was self paid, most of the medicines by way of tablets were purchased by us outside of hospital pharmacy. Thus I would not have used at least $ 50,000 of the deposit for the transplant due to early recovery and purchase of medicines outside of the hospital. To summarize, based on the estimate which was given for an average case (whereas my recovery has been above average), our bill should not have been more than $ 225,000 until end of August 2010. Considering the insurance coverage from 1st July, 2010, the bill should not be more than $ 200,000 whereas the bills total $ 434,000 as of date.

o       There was no communication from anyone in the hospital until the last week of May 2010 post the transplant that I can apply directly to companies manufacturing drugs and seek assistance. Though late, we approached the companies through Mr ..., Patient Reimbursement Specialist and convinced some of the companies to provide assistance to us. Some companies agreed but some did not, saying that they don't cover treatment for past dates and would cover only for future consumption. One such replacement we could succeed was for Clofarabine for which we were debited $ 119,250; we have talked to the company directly several times and convinced them to support us before they agreed to the same. Ms. ... also confirmed that   the replacement medicines have arrived and she would reverse the amount by end of this month and that would reflect in the bill by the first week of July, 2010. To conclude, we have put in efforts to secure 100 % replacement for many of the costly medicines; the pharmacy has charged at least 5 times the prevailing market price in US, but has agreed to just 15% discount.

o       The estimate given by the hospital for entire transplant and post discharge of 90 days was exhausted even before the transplant had taken place giving my family unbearable shock and distress. No one has explained to us about the cost of the medicines or treatment for the plan chosen. We were repeatedly told that the estimate is based on the average and if there are no complications or above average, our spending will be much lower than the deposit paid.

o       The price charged by the hospital for us after the discount is much higher than price charged to insurance companies who were able to negotiate. Considering the fact that I started my employment on 1st May, 2010 we have requested a higher discount as you would have given to any large insurance company. This would help us financially to cope with the present situation.

o       We have also explained to Ms. ... that from all the information we have been able to gather, the prices we have been charged by the pharmacy for medicines and the prices charged by the hospital for room rent, doctors' visit, labs and diagnostic investigations are much higher than the price paid by insurance companies.  We were advised by one of the large insurance companies that a similar transplant from investigations, harvest, hospitalisation and transplant to post discharge activities would cost about $ 145 k as compared to $ 434 k which is billed as of date. Hence our request for a higher discount rate, trusting the words of Dr ... and Dr ... who agreed to find a fair solution. We are sure that you can verify these numbers as you have all the information with you. We are sure that our request for a higher discount is reasonable and would qualify very well in the definition of "fair solution" as committed by Dr ... and Dr .... When we are charged over 60% higher rates than that of market rates or insurance company rates, we deserve much higher discount than the 15% offered now.

I would have expected a bit more sensitivity and consideration towards a patient's situation, that too to a patient who is doing everything to follow the rules and who paid upfront the entire amount after having borrowed the funds. First of all, communication and information appears to be rather disjointed giving rise to unnecessary confusion and misinterpretation. Secondly, since we were forced to borrow funds at high interest rates, I have repeatedly requested for consideration for a slightly higher discount with your business service and the finance offices.

While I fully appreciate your kindness in agreeing to a discount of 15% on gross billings, I have given all the justification as to why it has to be more than what you have given. Also, we completely trusted the words of Dr ... and Dr ... that they would find a fair solution and we feel that what has been offered does not appear to be fair and hence our appeal. I sincerely request you to allow me the privilege of meeting with you in the hope that at least I can come across and convince you for a higher discount. Your kind consideration in this regard will be highly appreciated.

Regards,

Krithi Ramamritham