This week an important investigative article was published by Time Magazine written by Steven Brill. In the best tradition of muckraking, Mr.Brill brought to light the labyrinth world of hospital and medical billing. It is wonderful when facts are brought into the antiseptic of sunlight as is the case in this article. The high charges that plague health care can be reality and lead to tragedy for some, or just a convenient benchmark for the lower prices that are the norm in much of the health marketplace. Mr. Brill brings this complex reality to light and does an outstanding job in communicating the complexity and the incoherence that is billing for health care services.
Good investigative journalism, in exposing facts that need exposing, can sometimes turn a simple tragedy into a morality play. In this case, instead of the simple tragedy that is caused by history, rules and regulations, we are given the morality of the greedy hospital executives and the heroic Medicare regulators. The hospital executives are taken to task for high salaries and for the huge mark ups. The Medicare regulators are lauded as knowing the right prices for everything and for working hard to help the people who have to deal with these greedy hospitals. This is where the article loses its focus by trying to be dramatic. The mundane facts are that hospital executives are usually hard working people who really care about the people being treated by their institutions just as Medicare people are usually hardworking people who care about the people helped by Medicare. In many ways, each are playing their role with the hospital executives merely being human and playing the cards they are dealt and the Medicare regulators doing the same. Those cards includes a legislative and regulatory backbone that rewards sky high charges and actually punishes those systems that try to be more rational in their approach to charges. As Brill points out, if the charges are high then the discounts against charges also remain high. This comes to light through the article as Brill talks about the amounts that hospitals actually receive compared to those charges.
Brill is at his best when he describes the trauma that people go through with high medical bills. Yet he also seems to miss the point at times. In his description of Janice S, he says, “We cannot know why the doctors who treated her ordered the more expensive tests” yet he describes events as if he does know. And that fundamental incongruity leads to conclusions that can misrepresent how events actually happen in the diagnosis and treatment of people’s illnesses. Often doctors order tests because they don’t know where the results of the tests will lead them and they are afraid of missing something that could potentially help the patient. Often doctors are worried about the “low probability, high consequence” events that while unlikely, if missed could lead to catastrophe. So trying to judge the billing by the final diagnosis rather than by the process that the doctor went through is inherently wrong and can often make the most diligent and well-meaning physician seem either greedy or incompetent when in reality he or she was doing a good job for their patient. Janice S was being evaluated for possible heart disease that could have been acute and fatal. We all celebrate the fact that it was indigestion however the doctors did not know that at the time. It may be easy to think that it is defensive related to malpractice or that the hospital is encouraging the use of expensive tests to gain revenues but I think the reality is that the doctors are just trying to do everything to help the patients. Janice S’s problems were unique to her and the physicians treating her made decisions based on how she presented at that point in time. They may have been wrong in their assessment but I will not impugn their morality or integrity in the decisions they made.
Mr. Brill talks about the fact that MD Anderson and Sloan Kettering have high priced executives and collect about 50% of their charges due to their brand recognition compared to about 35% which is the hospital industry average. It may be brand recognition but it may also be because they really are better run and treat the highly complex patients who find their way to their doors in a manner that is more conducive to cure. Mr. Brill tells the story of Alan A. who is told that he has no hope and then goes to Sloan Kettering, is treated, and is still alive 11 months later. For me, that part of the story is at least as important as the fact that the costs were high.
I am not defending the billing practices and that is not my goal. They are awful and should change. But if we change in such a way that we look at health care as a commodity, when it really is an art and a science that is highly dependent on the skill of the individual artisan applied against the complexity of the individual patient, then we will go backwards and not forwards. Do we really think that a community hospital in central Florida gives the same care as the MD Anderson Hospital? I know that I don’t believe that. Every day I am asked to recommend doctors and facilities for people with very complex illnesses and it is rare that I will recommend a doctor or hospital that practices in a small to mid-size hospital as they are unlikely to see complex people in the volume that is needed to stay proficient in their care. That is not an insult to those fine doctors and nurses who are in the trenches helping people every day with primary and secondary care but instead a comment on the fact that people need to have as their care givers, professionals with skills that are unique to the person needing help and the situation that they are in. Products or services sold as commodities are just the opposite. They are all the same so they can all be sold at the same price and negotiated mainly by price. That is part of the challenge with Medicare.
Medicare, even with their formulas and rules and regulations tends to look at health care services, as commodities. And lest you think that Medicare has all the answers and actually pays hospitals what they need to not only survive but thrive, think again. Those formulas that Mr. Brill accepts at face value are from the same people who bring you the crumbling infrastructure of the highways and bridges in this country. Medicare officials and policy people do their best but their struggle is always to keep afloat a system that must be built for the people who tend to be “routine” and not necessarily for the complex people who don’t really fit the system. There are special codes and formulas that are supposed to reflect the realities of different geographies, different types of hospitals and different payer mixes however they are also subject to political pressures (there is plenty of lobbying as Mr. Brill points out) and to budget challenges that can change the dollars available. And they cannot reflect the social, economic, and cultural differences of the individuals in need. Those complexities with the emotional upheaval of illness are also part of the realities of medical care.
So let the sun shine in. Let’s stop the insanity of charges that are jacked up in order to justify huge discounts down the road. Let’s stop the “unbundling” of services and products that should be included in a set fee. Let’s encourage and help every patient to negotiate the fees they are charged and understand that they have power in the relationships with the health facilities and health professionals. Let’s make health care affordable and accessible for all who need it. At the same time let’s acknowledge that people are not widgets and that the idea that one size fits all in medicine may lead to lower costs but will also have the potential to hurt a lot of individuals along the way.