Doctor's orders: Spiked bill has him lauding Obamacare
The Supreme Court's surprise ruling to uphold the highly controversial "individual mandate" component of President Obama's Affordable Care Act, a rule practically requiring all Americans to purchase some health insurance, has one local man hailing the decision as a big win for all Americans, particularly after an incident with his own medical bills.
"This is amazing news," says Craig Evans, an energy consultant who works in downtown Charlottesville, on the morning the Supreme Court issued its ruling. "The Affordable Care Act is good news for people like me who self pay."
The turmoil over the ouster of University of Virginia President Teresa Sullivan and the ensuing debate over how UVA should deal with 21st century challenges to the traditional college system wasn't lost on Evans, who has a cautionary tale about his own 21st century experience as an uninsured patient at the UVA Medical Center.
For Evans, the problem started last July, when he went for a routine blood test. He had recently switched doctors, which meant switching from Martha Jefferson to UVA. One thing, however, was not routine: the bill.
Evans who had been paying $91 at Martha Jefferson, found himself facing a $424 bill for the same procedure at UVA. As he began piecing together why he was effectively facing a 450 percent price spike, Evans made some startling discoveries about the small segment of the population who opt to self-pay their medical bills instead of buying in to what Evans sees as an inefficient and often predatory health insurance market.
“The U.S. healthcare budget is bigger than the entire budget of France,” says Evans. “Other countries have totally comparable healthcare at a fraction of our cost.”
Unlike many of America’s 50 million uninsured, who are indigent, careless, or just struggling to pay bills, Evans made his decision to go it alone with deliberation. Not long after deciding to self-insure, in November of 2010, Evans’ wife needed gall bladder surgery, and the bill came to $24,000. Big mistake? Evans says he actually saved about $10,000.
Here's how he figures. Evans had been paying an $1,800 monthly premium with Blue Cross/Blue Shield, on top of which he was responsible for the first $5,000 of any non-routine procedure. Throughout 2010, as healthcare became a hot-button political issue and providers anticipated new laws by raising rates, his premiums were soaring, eventually topping $3,400 a month, which meant his annual cost, including deductible, was heading toward $45,000. Despite paying for his wife's surgery out-of-pocket, Evans finished out 2011 by spending about $34,000— a whopping $10,000 less than what he would have paid an insurer.
As for the unexpected price of his blood test, Evans discovered that UVA's cost structure included multiple charges: a physician fee of $146 and a facilities fee of $191– on top of the fee for the test itself.
When Evans complained, his doctor and the lab technician expressed surprise. Evans’ doctor, Richard Santen, even raised the issue at a monthly meeting of UVA endocrinologists. According to Evans, Santen noted that UVA not only charges more on average than Martha Jefferson but more than the renowned Mayo Clinic.
Evans figures that a double-charge isn’t necessarily unique to UVA, rather that most patients simply don’t notice such additional fees since insurers generally cover the majority of any procedure. As someone who scrutinizes every bill, files every invoice, and triple checks every price list, Evans felt his story should be shared to help others.
In an e-mail to Dr. Santen, one leading UVA endocrinology doctor called the hospital's price structure "mostly meaningless." When confronted with Evans' billing woes, this doctor pointed out that the small group of people who forgo insurance are trapped in an "unfortunate game" played by hospitals and insurance companies.
A document prepared by the UVA Medical Center in response to a reporter's questions outlines why UVA patients might see higher street prices than at a community hospital like Martha Jefferson. The document points to UVA’s wider range of services— like inpatient psychiatric care and a Level 1 trauma center— and the fact that as an academic medical center it treats a higher volume of uninsured and under-insured patients, many of whom qualify for charity care if deemed unable to pay their medical bills. While the document indicates that UVA aims for the median prices of comparable peer institutions, it concedes that UVA fees are currently above the median.
A recent study from the non-profit Commonwealth Fund found that over half of the insurance plans sold on the individual market would fail to meet the standards put forth by the Affordable Care Act– the so-called Obamacare which aims to overhaul U.S. healthcare by requiring everyone to purchase some minimum insurance, prohibiting providers from denying patients with pre-existing conditions, and establishing higher standards of care. The legislation has been met with heavy criticism from policy experts who question the seemingly opposed goals of improving and expanding coverage while slashing overall costs.
Though small, the shift away from insurance consumption by people like Evans reflects a U.S. healthcare market in distress. Evans' choice to opt out of health insurance could become illegal– and unnecessary, he hopes– under the Affordable Care Act's "individual mandate." But Evans hails the Act and the Supreme Court's June 28 decision.
"The Affordable Care Act is going to help to eliminate the problem I’ve identified," says Evans. "Hopefully, charges for medical services are going to be made even across the board, and people who don’t have affordable insurance can afford insurance."
UVA Board of Visitors rector Helen Dragas highlighted the need to strategically plan for a “rapidly changing health care environment” in a letter e-mailed to UVA students and faculty June 22 that offered a list of explanations for her ouster of Teresa Sullivan on June 10. She wrote about the need for a strategic plan and “very ambitious interim steps."
The dual goals of remaining competitive in the private healthcare sector and staying in the median price range of academic medical centers may call for tough decisions, especially when current costs—of healthcare and health insurance—already place heavy burdens on the public.
After relentlessly pressing his case to the higher-ups at the UVA Medical Center, Evans did get his bill reduced, although this “carrot,” as Evans describes it, still left him paying twice as much as he'd grown accustomed to paying at Martha Jefferson. After a subsequent visit to UVA, he did notice that he was no longer getting charged the additional facility fees– a result, he surmises, of someone flagging his account after he so vigorously fought the charges.
He says the lesson to self-payers is clear: when every bill is coming out of your pocket, it pays to crunch the numbers. And it pays even more to make some noise.
“Insurance companies like to play games with the rates,” says Evans, asserting that while healthcare and insurance providers may like puffed-up hospital bills, they can become a big loss for those, such as Evans, who would otherwise be better off self-paying.
“There’s this small population of people," says Evans, "who slip through the cracks."