A Trip to the ER & Thoughts on Health Care

I arrived home Saturday from my weekly grocery run to find my Dear Husband (DH) splitting and stacking firewood with his friends. As I unloaded the car, I noticed that he was splitting wood using only his left hand, holding his right arm close to his side. I asked, "What did you do to your hand?" His response? "I think I broke it."

A trip to the wonderful ER at Alton Memorial Hospital confirmed that he had, in fact, sustained a small "chip" fracture of one of the carpal bones in the right hand. Our experience at the ED was great - the triage nurse was very kind & explained how the ED was set up and why she was sending us through the South ER, the registration staff was nice and thorough, the doctor showed us the fracture on screen & and our entire time at the facility was only about one hour. Monday, DH visited an orthopedic surgeon for a follow-up visit. He now has a cast and orders not to return to work until after he revisits the surgeon in two weeks.

In all, this little incident cost us a few hours of our time, $100 for our ER co-pay, $20 for the orthopedic surgeon's co-pay, and another $20 for the follow-up. We'll end up paying 5% of the total radiology charges, but all told it's not much out of pocket, especially after the supplemental insurance DH has kicks in -- I have no complaints about our health insurance.

I wonder, however, what situation we would be in without the coverage we have. a quick search of msnbc.com yields numerous articles about disparities in health care coverage, rising costs and shrinking coverage. Combined with the seemingly-unending number of layoffs affecting our country these days, the number of people with inadequate coverage - or worse, none at all - keeps climbing.

There are multiple reasons why I care about this situation. Primarily, it's because I'm human, and the suffering of others bothers me. I find the thought of children without preventive care, elderly folks having to choose which medications are most important, or families having to declare bankruptcy thanks to an unexpected illness disturbing, if not disgusting.

Secondly - though definitely less empathetic - I don't like the idea of paying for a flawed system. I have no problem paying taxes to fund Medicare, Medicaid or Social Security. I am a firm believer that our country should provide health care for its citizens when they are unable to work or have retired. My problem is with the way these programs compensate providers for services, and how privately-insured folks (like me) end up paying extra to subsidize care.

What am I talking about? The cost shift - sometimes referred to as health care's "dirty little secret" - in which private insurers pay more than the cost of care to make up for the fact that Medicare & Medicaid pay less than the cost of care. Let me break it down using data from the St. Louis Business Health Coalition's 2007 Health Care Industry Overview. For the sake of simplicity, we'll use round numbers to start with, and let's say my insurance company covers everything past my co-pay.

Let's start by sending me to the ER and supposing that the total cost of my trip was $1000. We'll use data from 2005, the most recent available in the BHC report.

In order to cover staff and other overhead, Alton Memorial Hospital (AMH) has a mark-up of 203.5%. This means that, when they put our bill together, the total charge for our trip to the ER is $2035. I paid a $100 co-pay, so AMH will bill my insurance company $1935. (For the sake of comparison, the mark-up at their closest competitor, St. Anthony's Health Center - Alton, is 251% and the mark-up at Tenet's Des Peres Hospital is 343.7%)

AMH is a member of the BJC HealthCare system. Their reimbursement rate from commercial insurers (like mine) is $1.38 per dollar charged. That means that when my insurance company gets a bill for $1935, they will cut a check to AMH for $2670.30. That's $735.30 more than the charge - and $1670.30 more than the actual cost of services. What the heck?

Here's what you didn't know - at the same time I was in the ER, so was Jane Doe - who's insured by Medicare. Jane's trip to the ER also cost $1000, she also paid $100 as a co-pay, and AMH also billed Medicare $1935. Medicare, however, reimburses $0.94 per dollar charged, which means that the check AMH gets from Medicare is $1818.90, which is $116.10 less than the charges and only $818.90 more than the actual cost of care. This leaves AMH $116 below what they need to minimally keep up with overhead and pay their staff - wherever will they find that money?

Oh wait . . .

Me.

Yep, they're going to take that extra $735.30 from my insurance company, subtract $116.10 to make up for the shortfall from Medicare, and they'll be left with $619.20 to put toward investing in new equipment, upgrading older items, community outreach programs, and writing off bad debt from folks who don't pay them at all.

So I help pay for Medicare (and Medicaid, which has the same reimbursement rate) through my taxes and through my health insurance? Do you see my problem with the system? I pay $50.30 per pay period for my health insurance - which I am not complaining about. That's $1307.80 per year. But based on what my company pays out to providers, I'm really paying $947.68 for my health insurance, and $360.12 to subsidize Medicare & Medicaid. As I said in the beginning, I have no problem paying taxes to fund such programs, but subsidizing them using my health insurance seems like a sneaky way to do it.

If you've read this far hoping for an answer to the problem, I'm sorry but you're out of luck. I think this topic, like many, is complex enough that everyone should research in order to make their own decisions. But here are some places to start:

Here is a link to the Obama-Biden health care plan. I think it makes sense, but I also think it will hit a lot of opposition from the Right. Big surprise.

In a Letter to the Editor of Modern HealthCare Magazine, Steve Lipstein, President and CEO of BJC HealthCare, states that the Blue Ridge Academic Group has offered a suggestion for

"the creation of a United States Health Board, legally chartered and established by Congress in a fashion similar to the Federal Reserve.

. . .

"The policy paper suggests that the enabling legislation transfer authority over the regulation and supervision of all health insurance from the states to a United States Health Board. Congress would set the guiding principles that would govern the Health Board’s regulation and supervision role including:
All citizens would have guaranteed access to insurance whether they are employed or not, rich or poor, pre-existing condition or not.
Premiums would be affordable, as would out-of-pocket cost-sharing.
"Americans would have choice of physicians, hospitals and insurance plans. With these principles as guideposts (similar to low inflation and full employment as guideposts for the Fed), the United States Health Board could use its power of regulation and supervision to achieve these desired outcomes."

The paper is available here.

Something I would like to suggest, however, is that no matter what anyone says, the question is never one of how to afford whatever changes are deemed necessary. The question is of how much it is worth to us - as a nation and as individuals - to care for our fellow citizens as we would like to be cared for. If we all looked at the uninsured child as our own, if we pictured our own parents or grandparents having to choose between medications and heat, if we visualized ourselves bankrupt because of an illness; I have a feeling we would find the funding to fix the system.



Today's positive item:
The area I now call home is famous as being the wintering home of bald eagles. What doesn't seem to get as much attention is the fact that, because we're right on the Mississippi Flyway, we also get tundra swans and American white pelicans. There is a remarkable feeling that overtakes me when I see this:

But I get another, different feeling when I look up and see this:
Or when I look out across the water to see this:

It took some pondering, but I think I finally realized what it is -- the realization that although it can be wonderful and refreshing to fly solo, above the noise and the fray, concerned only with your own needs; there are times when you need others to keep you company, make life easier, and watch over you while you sleep.