An emergency room story to make anyone ill

By Attorney David Engler

Have you ever received an Explanation of Benefits letter from your insurance provider and cannot figure out what you owe? You are not alone in deciphering a hospital bill. At http://www.latimes.com/health/la-me-lopez-medicalcosts-20120325,0,6538717.column/ Steve Lopez describes how a father received a $5000 dollar emergency bill for his daughter’s tummy-ache!

STEVE LOPEZ

So they went to Providence Tarzana Medical Center’s emergency room, where Moser handed over his insurance information. He had lost his job in TV production, and later bought his own medical insurance. To keep the monthly premiums manageable, he went for a plan with a $5,000 deductible.

“I kept asking, ‘Is this really necessary?’ ” said Moser, who first questioned the emergency room staff about the need for an IV drip to administer a saline solution.

The staff agreed not to do the saline solution. After some blood work, the doctor recommended an ultrasound, which Moser questioned. He relented, though, when the doctor said it wasn’t absolutely necessary but would rule out anything serious. And it did, so Ella went home with what was diagnosed as nothing more than an upset stomach, from which she quickly recovered.

But when the bill arrived, John Moser felt a sharp pain in his own gut.

The cost for just walking in the door of the emergency room? That came to $1,288. The ultrasound nicked him an additional $1,135. A comprehensive metabolic panel (blood analysis) was billed at $1,212.

Moser was also charged $158, accidentally, for the saline solution he had turned down. The total came to $4,852.55, not counting separate bills that would arrive later and total nearly $1,000, including $540 for pathology and $309 for the doctor.

“I was shocked,” said Moser.

The first bill, $4,852.55, was confusing, as medical bills often are. It said “your health plan has recently made a payment on your account.” It said the balance, $2,571.85, “is now your financial responsibility.”

When Moser mentioned the bill to his father, Marvin Moser flipped.

“Yes, the fees in ERs are off the wall all over the country,” the professor of medicine told me, but he found Tarzana’s to be extraordinary. “The one thing that stands out, beyond belief, is $1,212 for a metabolic panel.”

That’s a test, Dr. Moser said, in which a technician draws blood for chemical analysis, and it takes just minutes. Moser questioned not only the charge, but the usefulness of the test in his granddaughter’s case.

Out of curiosity, I went online to see what a lab might charge for a comprehensive metabolic panel.

Any guesses?

Some labs advertise prices as low as $39.

Glenn Melnick, who teaches hospital economics at USC, was not surprised.

“By and large, these prices are fictitious numbers,” said Melnick, who argued that Tarzana and most other hospitals routinely charge astronomical fees, especially for emergency room services.

Of course, and it’s all part of a years-long game in which the charge for service, the true cost of the service, and the acceptable payment are in three different orbits. And that doesn’t even take into account how the charges are adjusted up or down depending on who’s paying them and whether they have worked out a deal. How can patients hope to make sense of such an indefensibly convoluted system?

Starting Monday, President Obama’s healthcare reform act will get a hearing before the U.S. Supreme Court. But how can you have an honest conversation about soaring healthcare costs and health insurance, Dr. Moser asked, without addressing the maddening fictions built into the system? Patients seldom know in advance what they are being charged, he said, and many later find themselves in “medical bill bankruptcy.”

Melnick said hospitals argue that they lose money providing service to the uninsured, and by not getting reimbursed enough for Medicare or Medicaid patients. There’s some truth to that, Melnick said, but prices are set artificially high to help balance the books on the backs of paying customers. In the case of a $1,200 charge for entering an emergency room, Melnick said, the Medicare reimbursement is likely to be $300 or less, and far closer to the hospital’s true cost.

“Hospitals have figured out they can rapidly increase charges in the ER,” Melnick said, “and that will lead them to get higher amounts even from insurance companies they negotiate with.”

This is a very big deal, Melnick said, because half of all patients admitted to a hospital in California go in through the emergency room. Melnick said there’s also been a huge increase in the number of patients who lost group coverage and purchased individual plans with high deductibles, making them more vulnerable to exorbitant charges.

“More and more, people are seeing their deductibles eaten up on one visit.”

Melnick directed me to a state website (http://www.oshpd.ca.gov/chargemaster/) where every California hospital lists its fees. I did a little surfing and it appeared that the comprehensive metabolic panel for which Tarzana charged $1,212, Cedars-Sinai Medical Center lists a price of $786.45 and Ronald Reagan UCLA Medical Center charges $350.

A Tarzana spokesperson, Patricia Aidem, sent me a statement defending Ella’s care. “A child’s life was in our team’s hands and they acted accordingly…” said the statement.

It added that Providence hospitals spend millions each year on charity care for those who can’t pay. Aidem also provided data from the state website showing higher fees at other hospitals than Tarzana charged in the Moser case, including $2,678 for an abdominal ultrasound at West Hills Medical Center and a $4,413.24 emergency room visit at Cedars.

But that’s just the point. The price swings are so dramatic that they seem arbitrary, if not indefensible. I can’t predict how the Supreme Court will rule on healthcare, but I’m prepared to issue my judgment: It’s a mess.

(Look for a column in the next week on how the bill for Ella Moser’s tummy ache was settled and tips on how to avoid going broke from a minor medical emergency.)

steve.lopez@latimes.com

Attorney David Engler
Phone: 330-729-9777
http://www.DavidEngler.com Attorney Engler’s website
Areas of Practice: Family Law, Elder Law, Domestic Relations, Bankruptcy, Criminal

Also published on Attorney David Engler’s Blog on March 26, 2012 http://davidengler.wordpress.com// and Family Fault Lines Blog http://familyfaultlines.com//

Age and Its Awful Discontents

By Attorney David Engler

In my earlier blog I wrote about my Mother finding a new friend in the weeks of her final dawn. “Wanda and Stella” was about the two WWII era nurses that made a pact to go to heaven together.

Mom died on February 3, 2012 and Stella died March 3, 2012. The following piece is from Louis Begley who writes with beauty about friends lost as we age. This was published in the March 18, 2012 New York Times.

“My mother died in 2004, two days short of her 94th birthday, and 40 years and two months to the day after the death of my father. He died at 65; for the preceding four or five years he had been in poor health.

My mother and I lived through the German occupation in Poland; my physician father, having been evacuated with the staff of the local hospital by the retreating Soviet army, spent the remaining war years in Samarkand. Left to fend for ourselves, my mother and I became unimaginably close; our survival depended on that symbiotic relationship. All three of us — I had no brothers or sisters — arrived in the United States in March 1947, and once here I began to keep her at arm’s length. Especially during her long widowhood, I feared that unimpeded she would invade my life, the life she had saved. I remained a dutiful son, watching over her needs, but was at first unwilling and later unable to be tender.

My abhorrence of the ravages and suffering inflicted on the body by age and illness, which predates my mother’s decline in her last years, is no doubt linked to there being no examples of a happy old age in my family. The grandparents, uncles, aunts and cousins who might have furnished them all met violent deaths in World War II.

Unsurprisingly, dread of the games time plays with us has been a drumbeat in my novels. Thus, arms akimbo, majestic and naked, standing before a glass, Charlie Swan, the gay demiurge of “As Max Saw It,” illustrates for the younger narrator on his body the physiology of aging: misrule of hair, puckered brown bags under the eyes, warts like weeds on his chest, belly, back and legs, dry skin that peels leaving a fine white snow of dandruff. Listening to him, the younger man is reminded of his own father in a hospital, permanently catheterized, other tubes conducting liquids to his body hooked up to machines that surround his bed like unknown relatives. He prefers his mother’s “triumphant” exit. A headlong fall down the cellar stairs kills her instantly.

I have followed the progress into old age of Albert Schmidt, like me a retired lawyer, in three novels. Schmidt is 60 when we meet him in 1991; when we part on New Year’s Day 2009, he is 78, therefore a couple of years older than I was then. Life has not been kind to him, but so far, Schmidt enjoys excellent health, marching up and down the Atlantic beach in Bridgehampton and New York City’s avenues, and doing laps in his pool. Although he worries about performance, his libido is intact. Nevertheless, the reflection of his face in the window of a shop is frightening: he sees a red nose and bloodshot eyes, lips pursed up tight over stained and uneven teeth, an expression so lugubrious and so pained it resists his efforts to smile. My appreciation of my own charms is not very different. Like Schmidt, I see that nothing good awaits me at the end of the road, and that passing years will turn my life into a Via Crucis.

And yet my body, like Schmidt’s, continues to be a good sport. Provided my marvelous doctor pumps steroids into my hip or spine when needed, it runs along on the leash like a nondescript mutt and wags its tail. My heart still stirs when I see a pretty girl in the street or in a subway car, but not much else happens. Except that, since by preference I stand leaning against the closed doors, she may offer me her seat. When last heard from, Schmidtie figured he had another 10 years to live. I have a similar estimate of my longevity. Such actions as buying a new suit have become dilemmas. The clothes I have may be fatigued and frayed, but won’t they see me through the remaining seasons? Can the expense of money and waste of time required to make the purchase be justified?

My mother did not remarry after my father died. She lived very comfortably, but alone, in an apartment 15 blocks away from my wife’s and mine. If we were in the city, we went to see her often and then daily as her condition deteriorated in the last two years of her life. Our children and grandchildren tried to see her often, too — and those visits brought her great joy — but they live far away and the happiness was fleeting. During her last decade she was very lonely. Most of the friends she had had in Poland had been killed. Those who had escaped and settled in New York one by one became homebound or bedridden, lost their minds or died. Or she found they bored her. Hearing poorly, tormented by arthritis in hip and knee joints, too proud to accept a wheelchair, she stopped going to museums, concerts and even the movies. She had loved sitting on a Central Park bench and putting her face in the sun. That humble pleasure was also abandoned; she couldn’t get the hang of using a walker.

Having rehearsed the bitter gifts reserved for age, T. S. Eliot wrote in “Little Gidding” that “the end of all our exploring/ Will be to arrive where we started/ And know the place for the first time.” The closer that place — the human condition — is to home, the harder it is to take in. I could speak movingly of Schmidt’s loneliness after the loss of his daughter, calling his existence an arid plane of granite on which she alone had flowered. But it has taken me until now, at age 78, to feel in full measure the bitterness and anguish of my mother’s solitude — and that of other old people who end their lives without a companion.”

Louis Begley is the author of several novels, including “Schmidt Steps Back.”
A version of this op-ed appeared in print on March 18, 2012, on page SR7 of the New York edition with the headline: Age and Its Awful Discontents.

Attorney David Engler
Phone: 330-729-9777
http://www.DavidEngler.com Attorney Engler’s website
Areas of Practice: Family Law, Elder Law, Domestic Relations, Bankruptcy, Criminal

Also published on Family Fault Lines on March 20, 2012 http://familyfaultlines.com/

Medicaid Is a Big Number

By Attorney David Engler

$$2,300,000,000.00

Medicaid is a means tested program. That means you have to be poor to receive the benefits. And fortunately for all the medical providers, drug companies, nursing homes and home health care providers, an ever increasing share of America fits the definition of poor.

60% of all nursing home residents are paid for by Medicaid. 37% of all childbirths are paid for by Medicaid. It is a joint state and federal program. The wealthier states receive 50% reimbursement and the poorer states a larger share. 67 million people are receiving some type of Medicaid benefit. The last national figures showed us spending 2.3 Trillion Dollars per year. That is a lot of pace-makers, nursing home stays, physical therapy visits and above all drugs.

When we see the candidates running for office talking about balancing the budget, they cannot help look at the fastest growing expense in our country. But it is not only the advocates for the poor who push back but the advocates of the wealthy who have made a nice living off of serving the poor with medical care.

Attorney David Engler
Phone: 330-729-9777
http://www.DavidEngler.com Attorney Engler’s website
Areas of Practice: Family Law, Elder Law, Domestic Relations, Bankruptcy, Criminal