Thursday, July 22, 2010


Managed cardio care

My doctor — general practitioner — recently did a routine referral, sending me to a cardiologist for a stress test, because, well, I’ve reached the advanced age of 53 and haven’t had one, and I have a family history of heart problems. Results first, lest anyone be alarmed: everything is fine, and they have a baseline for future testing if it’s needed.

Specifically, I had a stress echocardiogram. A sonographer attached about a dozen electrocardiogram leads to my chest to monitor my heart, then took very cool pictures of my heart at rest, using ultrasound imaging. The focus, here, was on the blood flow to the heart muscle. The cardiologist came in, and they put me on a treadmill, monitoring all the while. Every three minutes, the treadmill sped up and increased its steepness. They’re looking for me to get to my target heart rate and stay there or above for bit.

The target heart rate is a strange thing, by the way, as it’s rather arbitrary. You figure your maximum heart rate by subtracting your age from 220, as though 220 were a magic number, and magic things happened to you at each birthday. Anyway, that puts my maximum at 167. The target rate is then 85% of that, 142 for me.

After 10 minutes or so on the treadmill, they turned it off and had me lie back on the table as quickly as I could, so the sonographer could repeat the ultrasound pictures with my heart working hard. They can then compare the before and after pictures to see if there are problems with the blood flow under stress. As I said above, there weren’t.

As you might imagine, given that I’m occupying a sonographer for some 45 minutes and a cardiologist for 15 or 20 minutes, and using an exam room, an ultrasound imager, a treadmill, a heart monitor, and so on... it’s not an inexpensive test. I got my insurance information, the explanation of benefits, the other day.

The cardiologist billed $1750 for the whole procedure. But here’s the interesting part: the insurance company discounted that by about $1240. That’s the amount that the doctor agrees to eat, as a cost of participating in this insurance plan, and that brings the amount that he actually gets for the procedure to about $510.

Let’s go over that again: he bills $1750, but accepts just $510, by agreement with the insurance company.

And that brings up a question: Who pays retail? That is, who, if anyone, actually winds up paying $1750 for that procedure?

If everyone with insurance pays a discounted fee, then it would have to be the uninsured people who pay the full one. But that doesn’t make sense: the uninsured are generally the ones least able to afford the full fee. And I’m told that doctors will routinely negotiate discounted fees for people without insurance.

What I get from this is that the full fee is actually an inflated one that’s designed to draw a higher discounted amount from the insurance company. Something like, Ask for $1500, hope for $1000, be happy with $500. Most of us have seen that sort of thing in other contexts.

But what does it say about managed care? Is it really keeping costs down, or are doctors just compensating by pushing their asking price up, requiring more pre- and post-procedure consultations — bringing in hundreds of dollars for spending ten minutes with the patient to explain the procedure, something that could be done with a leaflet the vast majority of the time — and using other techniques to keep the money coming in, in the face of more scrutiny by the insurance companies?

It seems to me that, in the end, the consumer isn’t winning here.

1 comment:

HRH said...

As you said consumer isn’t wining here. Also doctors aren’t that happy to deal with the insurance companies. A physician friend once told me, that the insurance companies publish their fee schedules for various treatments and procedures to the heath care community, and there aren’t any formal negotiations. Perhaps in the case you mentioned, another cardiologist in the area, could bill the insurance company $1950 instead of $1750, and would still receive the $510 scheduled fee for the stress test. Aside from the fee, dealing with the insurance company is an additional overhead for the doctor. Once, the “proper” claim paper works has filed with the carrier, the uphill struggle begins to get that check. Insurance companies often reject the claim based on technicalities, in most cases, just to delay the payment.
My brother owns his “oral surgery” clinic, he has hired one full time, dedicated person with great benefits, to just deal with the insurance companies. She knows all the appropriate codes for each procedure per insurance carrier, keeps up with the updates and changes to the codes (as they frequently happen), spends 6 to 7 hours a day on the phone with different carries, fighting the reject claims and still looses 2 to 3 percents of the claims, which adds up to a few thousand dollars loss per year.