Last winter, I banged my right elbow playing hockey, and it became swollen and red. Doctors diagnosed bursitis, inflammation of my elbow’s bursa sac, and prescribed antibiotics. In late May I became feverish and delirious. I checked into the only hospital in my hometown, Hoboken University Medical Center. An emergency-room physician, based on blood and other tests, diagnosed sepsis.
I spent three nights in the hospital, during which an orthopedic surgeon operated on my infected elbow. In a previous column, I praise my surgeon and others who treated me. These caregivers boosted my evaluation of American health care. I didn’t mention the costs of fixing my elbow because the bills hadn’t come in yet.
Now that my caregivers have billed my insurance company, I feel compelled to write this follow-up column. The bills for my treatment total $287,365.08. By far the biggest two items are the hospital’s bill, $185,037.45; and the orthopedic surgeon’s bill, $86,969.00. Separate bills from radiologists, anesthesiologists and other providers make up the balance.
The hospital’s $185,037.45 bill includes $13,500 for an MRI of my elbow, $9,500 for a CAT scan and $17,797.17 for two x-rays. “Laboratory” expenses, presumably related to blood tests carried out throughout my stay, total $44,787.96. The bill for my semi-private hospital room is $54,000, or $18,000 per night. The hospital’s charges strike me and two physicians I ran them by as high. For example, a medical-imaging website says “upper-extremity” MRI scans cost between $1,050 and $7,000; another site says overnight hospital stays average $11,700.
My personal payments, so far, have been minimal, because I am insured by Cigna Health through Stevens Institute. At the time of my hospitalization, neither my surgeon nor Hoboken University Medical Center belonged to Cigna’s network. Fortunately, Cigna authorized my hospital stay and surgery as “emergency treatment.” That means Cigna defines my out-of-network care as in-network because I lacked options.
But just because Cigna authorizes the treatment does not mean it must pay what caregivers charge. Moreover, caregivers can pressure the insurance company to increase reimbursements they consider too low. As of this writing, Cigna has reimbursed the hospital $50,816.82 for my room, according to data that Cigna posts on my online account. Cigna has denied all the other claims of the hospital. Hoboken University Medical Center, it’s worth mentioning, is owned by CarePoint Health, a for-profit corporation that has struggled financially.
Before operating on me, my surgeon assured me the operation would be straightforward, even “boring.” While I was under anesthesia, he cut a five-inch incision across my elbow and removed my bursa and other infected tissue. He also cut through a tendon to shave a bone spur off my elbow and sutured the tendon back together. He flushed out the remaining tissue with antibiotics and closed my wound with metal staples. All this took less than two hours, or so I recall; fever, medications and lack of sleep made me foggy-headed during my hospital stay.
As of this writing, Cigna has reimbursed my surgeon $2,495.18. His bill of $86,969.00 seems high, but Cigna’s reimbursement seems low. According to one site, elbow bursectomies average $10,186. A representative of my surgeon left a phone message saying I might be “liable” for the unreimbursed balance of his bill. She persuaded me to call Cigna and bring her in on the call, so together we could urge Cigna to increase its reimbursement. Cigna has not increased its payment as of this writing.
Meanwhile, my surgeon has billed me $77,299.22, almost the entire unpaid balance of his original bill to Cigna. Only recently have I learned that in fact I am not “liable” for the unpaid balance of my surgeon’s bill. New Jersey, my home state, bans billing patients for “out-of-network services provided on an emergency or urgent basis above the amount of the covered person’s liability for in-network cost-sharing.”
I’ve described my case to a few healthcare veterans, and they say it’s not unusual. Providers routinely overcharge insurance companies, which in turn routinely underpay the providers. Providers and insurers then haggle over the difference. Providers also seek reimbursement from patients, even though this practice is usually banned. All of this paperwork and haggling consumes time, energy and money.
Although my case is relatively simple, I am overwhelmed by the complexities of my treatment and its costs. I keep wondering about people with serious illnesses, like cancer, heart disease, diabetes and Alzheimer’s. How do they cope with the nightmarish financial consequences—on top of the physiological effects–of their conditions? I am more convinced than ever that American medicine is corrupted by capitalism—more specifically, by the desire of both providers and insurers to maximize profits–and needs radical reform.
The U.S. spends significantly more on healthcare per capita than any other country in the world, and yet its health is not proportionately better. Far from it. A recent comparison of the U.S. to “peer countries,” including Australia, Japan and the United Kingdom, found that the U.S. “ranks last in a measure of health care access and quality.”
Behind every medical story, including ones that end well, lurks the colossal dysfunction of American healthcare. My story ended well. I’ve recovered the strength and mobility of my right arm. I look forward to playing hockey again, with elbow pads, this winter. My elbow is fine. I wish I could say the same for our broken healthcare system.
Scientific Curmudgeon is an Opinion column written by CAL Professor and Director of the Stevens Center for Science Writings, John Horgan. Columns are adapted from ones originally published on ScientificAmerican.com.
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