Enjoy… or Improve the World? Sam Solves the E. B. White Conundrum

Our five grandbabies

Our five grandbabies

“If the world were merely seductive, that would be easy. If it were merely challenging, that would be no problem. But I arise in the morning torn between the desire to improve the world and a desire to enjoy the world. This makes it hard to plan the day.”
E. B. White

It is my birthday today. I have decided to give myself a treat. I am going to resolve the E. B. White conundrum. I am going to write a medical rant and then I am going to receive three of my granddaughters for a visit.

First, a medical rant

Six months ago I transferred my care to a local family practitioner at Island Family Medicine. He is a delightful and attentive doctor. He works in a friendly, professional clinic a few minutes drive from our home. In May, he recommended that I check my cholesterol, noting that I had not done so for several years and because he was about to refill my cholesterol lowering prescription.

I acquiesced because I did not want to alienate him so early in our relationship with one of my contrarian criticisms of the American health care system.

Yesterday I received a bill from the lab at Blue Hill Memorial Hospital that processed my blood. It was marked Past Due. It was a reminder that I had dragged my feet about paying $320.35 for getting my blood drawn for that cholesterol test.

As a physician who had run his own office in D.C. for many years, I knew that the national Lab Corp would have processed the specimen for $20 to $30. In turn, when I was practicing I would have charged my patient $40 to $50 to cover that cost and to interpret and advise them about the results.

I had contacted the lab director (who is a friend and who is not responsible for setting prices), the lab business manager and the hospital’s CFO to explain this to them.

A one thousand percent markup is not OK

I explained to the two executives that as a former trustee of Sibley Memorial Hospital, a small community hospital in Washington D.C., I understood the principles and problems with the “charge master” concept. I noted that as one of the growing number of people with a high deductible health insurance policy (Anthem BCBS paid $17.65 of the original $338 bill), I could not afford to pay for a service that was marked up 1,100%.

I asked them when a reasonable markup moved into the realm of an unethical markup and, perhaps, beyond that into criminal extortion.

The business manager and the CFO were endlessly patient.

They explained that their prices were “competitive” with other local hospitals. Note: in medicine “competitive” means providers raise their prices to equal their competition rather than lower their prices to give better service and attract more “business.”

They explained that they were a tiny community hospital that had to raise money wherever possible to cover their expenses. I noted that they were part of Eastern Maine Medical Center, one of the two large systems in this small state, and that it was my expectation that the system would subsidize its smaller providers.

They were sorry.

They promised that they would review the process. They understood that the price was high but their hands were tied. They noted that they discounted the prices to the impoverished on our island. They had to recover that cost somewhere. The CFO offered me a 10% discount.

I noted that I could pay $320.35 for a $30 service, but only once. Most of my neighbors cannot. And, what if I had a condition that required multiple and serial tests? Who can afford a one thousand percent markup on a regular basis?

Remembering a former patient who refused to switch to Medicare

I remember a lovely patient from many years ago. She and her husband were honest, loyal, smart, conservative, and principled. He was a government employee. She was a public school teacher. They were both healthy. They worked past the routine retirement age. When they turned 65 they refused to switch to Medicare and insisted on paying extra for private insurance and associated expenses.

Fifteen years before I left my medical practice I had removed a tiny cancer from her rectum. We monitored the site according to all the appropriate guidelines. Six months before I left my practice a similar cancer appeared in her liver without recurring in the rectum. Her medical bills were poised to skyrocket. I asked myself, how long would she hold Medicare at bay?

One million Americans go bankrupt annually because of our commercial insurance system. When will this system change? When will we recognize that the commercial insurance system is an unmitigated disaster? It was an understandable historical experiment given the American philosophy but it has failed miserably by enriching executives and impoverishing patients.

My $320.35 bill is small potatoes in the greater scheme of things but a one thousand percent markup is not.

I live in a little bit of heaven here on the Coast of Maine. Who would have thought that health care cost inequities would track me down?

And now to enjoy the day (my birthday)…

Now I am off to play golf. Then I will prepare my famous lamb burgers with anchovies and rosemary. My granddaughters will not be able to refuse them.

Useful reading

Medicare Turns 50 (July 30, 2015; nationwide rallies and events)

Paying Till It Hurts (New York Times blog on Facebook)

Bitter Pill: Why Medical Bills Are Killing Us by Steven Brill (April 4, 2013 in TIME magazine)

Physicians for a National Health Program

6 Responses to Enjoy… or Improve the World? Sam Solves the E. B. White Conundrum

  1. Brian Lockett July 23, 2015 at 10:27 pm #

    Love your columns, Sam. Admire your willingness to take on these issues. This from the boat in Newport. Headed to Maine soon. May be in touch then. Happy Birthday!

    • Debbie July 23, 2015 at 10:43 pm #

      Brian,

      I hope we see you! Let us know when you get closer to Stonington. xo

    • Sam July 24, 2015 at 8:01 am #

      Brian, tie up at the Stonington town dock. Ask any local where the old Colwell house – the one across from Reggie Greenlaw’s parking lot – is. It is a 200 yard walk. You will find us there if we are not out on the island. Safe sailing, Sam

  2. Susan Z. Martin July 24, 2015 at 3:59 pm #

    Sam – I echo the other commenter, love your posts although will admit I use them mostly as a cautionary tale to trot out when anyone here in British Columbia (Canada) starts complaining about our health care system. Is there a source for what people pay for insurance along with deductibles etc – we hear such widely differing numbers here in Canada. I wonder too why you had to pay for the test at all – since your doctor ordered it why is it not covered by your insurance? In case you are interested I pay $72 Canadian per month for my MSP (Medical Services Plan) which is mandatory for all BC residents. This covers me for doctors visits and pretty much any and all procedures unless they are deemed not medically necessary (i.e. I guess if I wanted plastic surgery of some kind). My late mother had surgery for ovarian cancer and 6 months of chemotherapy at no cost other than her MSP premiums. There are of course rules – when I asked for the CA-125 test (to look for ovarian cancer markers) the doctor said that having only a single female relative who had died from the disease was not enough of a reason so I would have to pay for it myself – $26!

    If you are low income you can apply to have your MSP premiums subsidized. MSP does not cover prescriptions but those are handled through a different government plan and I think make most drugs affordable. Unfortunately there is no vision or dental coverage unless you buy a private plan or have something through an employer. Overall though I am happy with the way things are though of course they can be improved and we have several problems common to any place with an aging population – long waits for joint replacement surgery, shortage of hospital beds in acute care because lack of extended care places and a severe lack of physicians so that many people are without a GP.

    Anyway – excuse the long winded comment but thought you might be interested. Keep up the good work/fight. Hope the book is going well.

  3. Neil Ravin January 15, 2016 at 10:07 am #

    Sam,

    Listened to Hillary Clinton last night on Rachel Madow and she pointed out that if Bernie Sanders did have to provide the details of a single payer system it would mean revealing it would be a trillion dollar proposition.

    I’m all set to vote for Bernie in the upcoming NH primary and one reason is his advocacy for Medicare for All. But I have no clear idea what that would really mean for the individual taxpayer or for the economy.

    Our current commercial patchwork medical system is so distorted (1000% mark ups not just for lab but for drugs) I’ve come to believe anything would be better. Maybe the Canadian system would work here.

    They hate Obamacare in Kentucky, but they love Kynect.

    Neil

  4. Sam January 18, 2016 at 2:28 pm #

    Neil, good to hear from you. I, too, have concluded that anything would be “better” (more honest, equitable, safer, sustainable and…you name it) than the current system and, having been to a colloquy on the subject, take comfort that those who have administered Medicare in the past say they can expand it to “all” in the future. Of course, only the political system and the Medical Industrial Complex stand in the way. The deeper Bernie goes in the process the sooner the former will be resolved. I wish I had a primary to vote in. Sam

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