Editor’s Opinion: Giving Sizeable Coverage to Billing Issues

  Not unlike scientific research, investigative journalism takes time, perseverance, and pursuit of the evidence. While pressure to follow a 24-hour news cycle and the number of ways to access that information has grown, the size of the medium we use to read about it — and our time to do so — has shrunken, literally, to pocket-size. Emphasis on the short story that fits on a small screen has increased, leaving readers with the mistaken impression they know the whole story.

  The real story and a real understanding of complex problems or research require much more screen (and print) space and much more time to tell and read. OWM readers are accustomed to (and deserve to be presented) the fullest picture possible on any topic we cover. Original research reports are never truncated for the sake of time or space because doing so would greatly reduce the value of the work and negatively affect its potential contribution to future studies. In the nonscientific press, however, the short story reigns supreme.

  Thus, when Time magazine editors decided to publish almost an entire issue on one topic, other reporters and the public paid attention, and talk about the article persists. “Bitter Pill; Why Medical Bills are killing us”¹ continues to be discussed, praised, critiqued, and reviewed. This is a must-read for everyone involved in healthcare; even if your patients have not asked you any questions related to the subject matter, you can be assured they will. The author spent 7 months following the money in the US healthcare system, starting with deciphering the hidden costs in hospital bills. His findings are eye-opening and eyebrow-raising, from revealing product and service mark-ups of 100%, 200%, or even 300% (eg, $77 boxes of gauze pads, $115 billed for a $35 vaccine) to hospital administrators with seven-figure incomes.

  At the heart of it all is the so-called chargemaster, a standard list of charges that increases every year. The chargemaster varies from hospital to hospital and, according to the Time investigation, does not appear to be based on anything objective. Hospital executives interviewed for the article generally didn’t think anyone cared because “most people never pay those prices.” Except when they do. Persons without health insurance are charged those prices, as are those with insurance limits or when noncovered charges are added. People with health insurance will see a discount on the chargemaster bill. But as the author discovered, even a 40% or 50% discount on a bill that contains 200% mark-ups means a lot of people are still paying too much and will pay more for the same care in one hospital versus another. For the healthcare system itself, this represents the principle behind a free-market system. Unfortunately for patients, that’s not the way it works. Even for elective procedures, comparison shopping on price is virtually impossible; in an emergency situation, there are no choices.

  The argument that the actual billing prices do not matter to patients rings increasingly hollow as the number of people with employer-sponsored health insurance and/or low-deductible insurance plans continues to decrease. According to a recent study by the Robert Wood Johnson Foundation-funded State Health Access Data Assistance Center,² the number of people covered by employer-sponsored health insurance decreased from 69.7% in 1999/2000 to 59.5% in 2010/2011, while average family premiums increased 125%. At the same time, more and more people pay their medical bills directly to care providers. US Census data³ show that between 2008 and 2012, the number of people covered by high-deductible health insurance plans more than doubled from 6.1 to 13.5 million. Typically, the first thousands of dollars in medical bills in a given policy year is paid by the patient. Are you able to tell them how much their treatment is going to cost? Do you know if your hospital, or hospital CEO’s salary, happened to be featured in Steven Brill’s investigation?

  Chances are your patients do. Moreover, not only are all of us patients at one time or another, but also everyone pays the price of a system that is unsustainable. The situation is complex, and even the extensive Time magazine expose does not cover all issues, angles, and aspects. But it is a very good start. Not unlike scientific research, the results of this investigative report warrant more study to find a solution that will help us provide optimal care, now and in the future.

This article was not subject to the Ostomy Wound Management peer-review process.

1. Brill S. Bitter Pill; Why Medical Bills are Killing Us. TIME. March 4, 2013. Available at: www.time.com/time/magazine/article/0,9171,2136864,00.html. Accessed April 15, 2013.

2. Sonier J, Fried B, Au-Yeung C, Auringer B. State-Level Trends in Employer-Sponsored Health Insurance. Robert Wood Johnson Foundation. April 11, 2013. Available at: www.rwjf.org/en/research-publications/find-rwjf-research/2013/04/state-level-trends-in-employer-sponsored-health-insurance.html. Accessed April 15,2013.

3. America’s Health Insurance Plans Center for Policy and Research. January 2012 Census Shows 13.5 Million People Covered by Health Savings Account/ High-Deductible Health Plans (HSA/HDHPs). May 2012. Available at: www.ahip.org/HSA2012/. Accessed April 17, 2013.