The $35 Solution

So much has been written about the excesses of health care and ways to reform, cut, improve or save the system.  I have a more modest proposal: Read the medical bill and get annoyed, like I did.

A year ago, our firm switched to a health savings account (HSA) system.  Previously, we had fully paid for our employees’ health insurance.  Under the new system, each employee has an HSA account and pays for health care services up to a specified dollar amount per year, the deductible, out of that account.  Once the individual reaches the deductible limit, insurance pays for all further services needed.  At our firm, the partners decided to pay the amount of each employee’s deductible.  For the employee, this means no out of pocket costs.  Meanwhile, the price of our firm’s overall health insurance costs went down.

I haven’t come to the proposal yet; but the HSA system led me to my proposal.

Now, when I go to the doctor, the bill still goes to my insurance company – that way, they can track how much of my deductible I have used – and then I get a statement for the amount I must pay for that doctor visit.  I send a check in to the doctor’s office and keep a copy for my records.

Since our move to an HSA system, I am far more keenly aware of what health care costs. That is part of the point of this approach.  If health care consumers are brought into closer contact with the business of medicine – by actually writing a check each time a health care service is provided – then the consumer may exercise some restraint in how health care dollars are spent.

Well, I have been brought into closer contact with the business of medicine and I am not happy.

A few weeks ago, I took my daughter to the pediatrician.  She was complaining of a sore throat and I thought it could be strep.  The nurse went through the usual motions, checking my daughter’s weight, taking her temperature, putting a pulse-ox clip on her finger, taking some history.  She swabbed the back of my daughter’s throat for the strep culture.  Then we saw the pediatrician, briefly, and were pleased to learn that the rapid-culture results were negative

Later I received a bill from the pediatrician’s office.  The doctor’s office had submitted the bill first to the insurance company, as usual.  The physician’s charges were reduced according to the provider agreement with the insurance company, again as usual.  In the past, my insurance company would have paid the balance due, but under the new HSA system I received a bill for the difference.  Previously, I would never have paid attention to what was charged and what was paid.  Because I am paying the bill, I looked over the statement to see what I was paying for.

The statement showed total charges of $195, but the insurance company contract with the physician’s practice resulted in a reduction of that amount to $135.67.  That seemed like a lot for one 15-minute visit to the pediatrician.  When I reviewed the line items that made up the charge, I looked through a window into the world of inflated medical bills.

The pediatrician charged $112 for the office visit itself.  Now, I really like our pediatrician.  We have used this group since the kids were babies.  Then again, I don’t think the doctor spent more than two minutes with us.  That’s it.  In and out and on to the next exam room where another patient was prepped and waiting to be seen. A charge of $112 seems awfully high for the amount of time the doctor spent on our case.  But, alright, maybe sometimes the encounter is brief and sometimes it is a bit longer.

Next, there was a charge for the rapid-strep culture: $48.  That seems reasonable.  That cotton-tipped swab gets run through a machine that quickly analyzes for bacteria.  If the result is positive, within a few minutes the doctor is writing a prescription for antibiotics and you’re on your way to your child feeling a whole lot better.  That charge seems well worth the while.

The final charge on the pediatrician’s bill is the one that most raised my hackles.  There was a charge of $35 for what the bill describes as “measure blood oxygen level.”  Thirty-five dollars to put that little clip on my daughter’s finger?  Seriously?

A pulse oximeter (pulse ox) measures the level of oxygenation in the blood.  The clip goes on a finger or the ear lobe, connects to a monitor and provides a result within seconds.  Pulse ox is useful in evaluating critically ill patients, such as someone who is very short of breath.  If a patient is not getting sufficient oxygen to the blood, as a pulse ox might indicate, then that patient might need supplemental oxygen to protect vital organs from damage.

I had never questioned the pulse ox during a routine pediatrician sick visit.  After all, it is a harmless, non-invasive little device.  Even if my child wasn’t huffing and puffing, I had always figured, it couldn’t hurt to know her O2 saturation level.

Now that I see the pediatrician gets to charge $35 for the “service,” I am questioning.  I know it’s only $35 and my insurance reduced the charge by $16.81.  So really I only have to pay $18.19 for the privilege of having the doctor (really the nurse) perform what I feel fairly confident was a totally unnecessary test.

Still, $18.19 from me, and from the dozens of other patients in that crowded pediatrician’s office over the course of a day, a week, a month . . . .well, now it starts to really add up.

I wouldn’t deny a pediatrician’s right to be paid for services provided.  Doctors have to make a living as we all do.  Still, there are countless ways to add charges.  Will there next be a separate line item for the disposable thermometer?  Or for the use of a stethoscope?

Moreover, this makes me wonder what other charges are being added to the bills of other doctor visits or hospital stays.  How else are we being hit with unnecessary charges, whether we pay for them directly out of an HSA account or whether we feel the bite of annual premium increases on our health insurance?

I don’t believe my daughter needed a pulse ox test when she presented with symptoms of a cold and a sore throat.  This is not a case of over-treatment; it really is a case of padding the bill.  Does it rise to the level of health care fraud?  I would think not.  But it does feel unnecessary and excessive in a world of limited resources and great health care needs.

I don’t know where exactly the line should be.  I cannot say what the pediatrician should include as part of the standard office fee and what should be an added, extra line item.  I am not an expert in what is medically appropriate or medically necessary.

If I had been asked before the nurse used the pulse ox, I probably would have known enough to question whether it was necessary.  If the nurse didn’t have a pretty good reason for the test, and if I had known there was an added cost for that service, I probably would have declined.  Or perhaps in that moment, with a sick child by my side, I would have thrown fiscal caution to the wind and left matters entirely to the judgment of the doctor and her staff.

Still, there has to be a check on health care costs.  There are a lot of agencies scrutinizing and auditing physician and hospital billing.  There is more pressure than ever on physicians to justify the tests and procedures used in the diagnosis and treatment of their patients and the bills for those services.

Consumers have a part to play as well, in my view.  So I am going to write a letter to the pediatrician.  I am going to ask whether that pulse ox was really necessary and whether it couldn’t simply be included in the standard charge for the office visit.

It has always been true that I have paid for medical care, but now, with the HSA system, I do feel much closer to the flow of health care dollars. After all, I am writing the checks.  That means I am going to continue to look carefully at my medical bills.  Chances are, I am also going to continue to be annoyed.

Just doing my part.